Bijo Chacko, MD

Got a job offer? Congratulations! The hard part of finding your first job after residency is complete. This also is a time to sit down and think about what’s important to you, as you want the details of your job to be stated in a contract. Here are some tips about contract negotiation.

Get It in Writing

Just as in practice, where we are always told, “it didn’t happen if it’s not documented in the chart,” the same holds true for your workplace contract. This is the time to prioritize what elements are important to you in order to have a satisfying and rewarding career, both professionally and financially. If a particular aspect of your employment agreement is important to you, be it salary, schedule, or malpractice insurance coverage, be sure its stated in writing in your contract. Verbal statements from your employer, such as “we’ll discuss this after you start your job,” should raise a red flag.

Know What Is Negotiable

Some residents are relieved just to secure their first job offer and they immediately accept the initial offer as-is, without attempting to negotiate. Although it’s probably unreasonable to negotiate everything, after you read the initial contract, if anything important is not to your satisfaction, it is practical to have a discussion with your employer. Employers expect this of their hires and, if done politely and professionally, this is a time to build bridges with your future supervisor. Moreover, they begin to better understand your needs and you theirs.

You may find it helpful to talk to associates in the group about what parts of their contracts were negotiable. For example, particularly in academic settings, you may find salary and benefits are not negotiable; however, other benefits, such as office space or protected research time, may be negotiable. Basically, the best time to negotiate is the “honeymoon” period, right after a job offer has been made, as the employer will be doing its best to entice a prospective employee.

Consider a Legal Opinion

In general, the more complex your contract, the more important it will be to solicit the help of an attorney experienced in healthcare. Even if your contract is very simple, contains a standardized salary and benefit structure, has no restrictive covenants, and partnership is not an issue, it may be helpful to have your contract reviewed by an attorney. Understand what is written in your contract and, if there is any doubt, hire a lawyer.

Ultimately, you will be signing the contract, not your lawyer, so be sure you understand what is in it and don’t get mired in “legalese.” Some firms offer third-party contract negotiation; they will assign an attorney to step in as an intermediary. Then again, most experts recommend against hiring a third-party negotiator, as this may increase the distance between you and your employer at a time probably best spent getting to know each other.

Maintain a Keen Eye

Specifics to look for in your new contract:

Work requirements. The employment agreement should visibly define your job responsibilities. Things to look for in your contract include the obligations of the physician, number of shifts or hours or weeks per year you are expected to work, call responsibilities, a census cap (if applicable), allotted vacation time, and continuing medical education time.

Compensation. The contract clearly should delineate how you will be paid. Some hospitalists are compensated solely via a salary; others are paid based on billing/productivity, while the majority are paid based on a combination of these methods (a base salary plus incentives). Be sure you understand the incentive and/or bonus structure of your salary. Practices basing incentives on physician productivity will incorporate your own billing practices and often is measured in relative value units (RVUs). In some settings, group incentives are based on quality targets set by the administration, such as the Joint Commission on the Accreditation of Healthcare Organi-­zations (JCAHO) core measure compliance, dictation timeliness, or patient/primary care physician satisfaction.

Benefits. In addition to your salary, you should see that your benefits are spelled out. The obvious benefits include medical, dental, and vision insurance, as well as a retirement savings plan. As discussed in the July 2008 issue of The Hospitalist, as demand for hospitalists continues to exceed supply, look for signing bonuses, coverage of relocation expenses, and the possibility of student loan payoff. Other important benefits include coverage of professional dues, CME allocation, and licensing and board examination fees.

Malpractice Insurance. This can be a complicated topic. In general, there are two major classes of malpractice insurance: an occurrence policy and a claims-made policy. In respect to an occurrence policy, any malpractice incident arising while the coverage was in place, regardless of when the claim was filed, will be covered even after you have stopped practicing under that policy. A claims-made policy, on the other hand, protects physicians for any covered claim, if they are insured when the claim is made. It does not cover malpractice claims filed after the physician cancels the malpractice policy, even if the claim is about an event that occurred while the physician was insured.

If you are offered a claims-made policy, require your employer to add tail coverage, which covers you after leaving the practice for any events occurred during employment. If you are unclear about any part of the group’s malpractice coverage, consider seeking legal advice.

Restrictive covenants. These are non-compete clauses often setting geographic and time restrictions of where and when a physician can practice in the event they leave the group. Though you never know what the future holds, this becomes relevant if you were to change jobs and work at an adjacent local facility or one in a nearby county. In general, hospitalists rarely carry a panel of patients, so an employer probably should not be concerned about hospitalists taking patients with them if/when they leave the practice. Be cautious of restrictive covenants found in your contract.

Ownership/Partnership. In some private groups, partnership will be offered after a preliminary employment period, usually one to two years. Look for your contract to state when and how partnership might be offered, and what the criteria to join are. This also is the time to ask others in the group to get a sense of how many associates are offered partnership and when this might happen.

Allowable Activities. Look for any restrictions regarding your activities outside normal clinical duties, such as teaching, research, or consulting for other firms. If such restrictions are in your contract, there may be specifications about whether income from such activities is yours or whether it is shared with the rest of the practice. TH

Bryan Huang, MD, assistant clinical professor, division of hospital medicine, University of California-San Diego Department of Medicine, Bhavin Patel, MD, hospitalist at Regions Hospital, HealthPartners Medical Group, St. Paul, Minn., Bijo Chacko, MD, hospitalist program medical director, Preferred Health Partners, New York City, and chair of SHM’s Young Physician Committee.

Got a job offer? Congratulations! The hard part of finding your first job after residency is complete. This also is a time to sit down and think about what’s important to you, as you want the details of your job to be stated in a contract. Here are some tips about contract negotiation.

Get It in Writing

Just as in practice, where we are always told, “it didn’t happen if it’s not documented in the chart,” the same holds true for your workplace contract. This is the time to prioritize what elements are important to you in order to have a satisfying and rewarding career, both professionally and financially. If a particular aspect of your employment agreement is important to you, be it salary, schedule, or malpractice insurance coverage, be sure its stated in writing in your contract. Verbal statements from your employer, such as “we’ll discuss this after you start your job,” should raise a red flag.

Know What Is Negotiable

Some residents are relieved just to secure their first job offer and they immediately accept the initial offer as-is, without attempting to negotiate. Although it’s probably unreasonable to negotiate everything, after you read the initial contract, if anything important is not to your satisfaction, it is practical to have a discussion with your employer. Employers expect this of their hires and, if done politely and professionally, this is a time to build bridges with your future supervisor. Moreover, they begin to better understand your needs and you theirs.

You may find it helpful to talk to associates in the group about what parts of their contracts were negotiable. For example, particularly in academic settings, you may find salary and benefits are not negotiable; however, other benefits, such as office space or protected research time, may be negotiable. Basically, the best time to negotiate is the “honeymoon” period, right after a job offer has been made, as the employer will be doing its best to entice a prospective employee.

Consider a Legal Opinion

In general, the more complex your contract, the more important it will be to solicit the help of an attorney experienced in healthcare. Even if your contract is very simple, contains a standardized salary and benefit structure, has no restrictive covenants, and partnership is not an issue, it may be helpful to have your contract reviewed by an attorney. Understand what is written in your contract and, if there is any doubt, hire a lawyer.

Ultimately, you will be signing the contract, not your lawyer, so be sure you understand what is in it and don’t get mired in “legalese.” Some firms offer third-party contract negotiation; they will assign an attorney to step in as an intermediary. Then again, most experts recommend against hiring a third-party negotiator, as this may increase the distance between you and your employer at a time probably best spent getting to know each other.

Maintain a Keen Eye

Specifics to look for in your new contract:

Work requirements. The employment agreement should visibly define your job responsibilities. Things to look for in your contract include the obligations of the physician, number of shifts or hours or weeks per year you are expected to work, call responsibilities, a census cap (if applicable), allotted vacation time, and continuing medical education time.

Compensation. The contract clearly should delineate how you will be paid. Some hospitalists are compensated solely via a salary; others are paid based on billing/productivity, while the majority are paid based on a combination of these methods (a base salary plus incentives). Be sure you understand the incentive and/or bonus structure of your salary. Practices basing incentives on physician productivity will incorporate your own billing practices and often is measured in relative value units (RVUs). In some settings, group incentives are based on quality targets set by the administration, such as the Joint Commission on the Accreditation of Healthcare Organi-­zations (JCAHO) core measure compliance, dictation timeliness, or patient/primary care physician satisfaction.

Benefits. In addition to your salary, you should see that your benefits are spelled out. The obvious benefits include medical, dental, and vision insurance, as well as a retirement savings plan. As discussed in the July 2008 issue of The Hospitalist, as demand for hospitalists continues to exceed supply, look for signing bonuses, coverage of relocation expenses, and the possibility of student loan payoff. Other important benefits include coverage of professional dues, CME allocation, and licensing and board examination fees.

Malpractice Insurance. This can be a complicated topic. In general, there are two major classes of malpractice insurance: an occurrence policy and a claims-made policy. In respect to an occurrence policy, any malpractice incident arising while the coverage was in place, regardless of when the claim was filed, will be covered even after you have stopped practicing under that policy. A claims-made policy, on the other hand, protects physicians for any covered claim, if they are insured when the claim is made. It does not cover malpractice claims filed after the physician cancels the malpractice policy, even if the claim is about an event that occurred while the physician was insured.

If you are offered a claims-made policy, require your employer to add tail coverage, which covers you after leaving the practice for any events occurred during employment. If you are unclear about any part of the group’s malpractice coverage, consider seeking legal advice.

Restrictive covenants. These are non-compete clauses often setting geographic and time restrictions of where and when a physician can practice in the event they leave the group. Though you never know what the future holds, this becomes relevant if you were to change jobs and work at an adjacent local facility or one in a nearby county. In general, hospitalists rarely carry a panel of patients, so an employer probably should not be concerned about hospitalists taking patients with them if/when they leave the practice. Be cautious of restrictive covenants found in your contract.

Ownership/Partnership. In some private groups, partnership will be offered after a preliminary employment period, usually one to two years. Look for your contract to state when and how partnership might be offered, and what the criteria to join are. This also is the time to ask others in the group to get a sense of how many associates are offered partnership and when this might happen.

Allowable Activities. Look for any restrictions regarding your activities outside normal clinical duties, such as teaching, research, or consulting for other firms. If such restrictions are in your contract, there may be specifications about whether income from such activities is yours or whether it is shared with the rest of the practice. TH

Bryan Huang, MD, assistant clinical professor, division of hospital medicine, University of California-San Diego Department of Medicine, Bhavin Patel, MD, hospitalist at Regions Hospital, HealthPartners Medical Group, St. Paul, Minn., Bijo Chacko, MD, hospitalist program medical director, Preferred Health Partners, New York City, and chair of SHM’s Young Physician Committee.

Got a job offer? Congratulations! The hard part of finding your first job after residency is complete. This also is a time to sit down and think about what’s important to you, as you want the details of your job to be stated in a contract. Here are some tips about contract negotiation.

Get It in Writing

Just as in practice, where we are always told, “it didn’t happen if it’s not documented in the chart,” the same holds true for your workplace contract. This is the time to prioritize what elements are important to you in order to have a satisfying and rewarding career, both professionally and financially. If a particular aspect of your employment agreement is important to you, be it salary, schedule, or malpractice insurance coverage, be sure its stated in writing in your contract. Verbal statements from your employer, such as “we’ll discuss this after you start your job,” should raise a red flag.

Know What Is Negotiable

Some residents are relieved just to secure their first job offer and they immediately accept the initial offer as-is, without attempting to negotiate. Although it’s probably unreasonable to negotiate everything, after you read the initial contract, if anything important is not to your satisfaction, it is practical to have a discussion with your employer. Employers expect this of their hires and, if done politely and professionally, this is a time to build bridges with your future supervisor. Moreover, they begin to better understand your needs and you theirs.

You may find it helpful to talk to associates in the group about what parts of their contracts were negotiable. For example, particularly in academic settings, you may find salary and benefits are not negotiable; however, other benefits, such as office space or protected research time, may be negotiable. Basically, the best time to negotiate is the “honeymoon” period, right after a job offer has been made, as the employer will be doing its best to entice a prospective employee.

Consider a Legal Opinion

In general, the more complex your contract, the more important it will be to solicit the help of an attorney experienced in healthcare. Even if your contract is very simple, contains a standardized salary and benefit structure, has no restrictive covenants, and partnership is not an issue, it may be helpful to have your contract reviewed by an attorney. Understand what is written in your contract and, if there is any doubt, hire a lawyer.

Ultimately, you will be signing the contract, not your lawyer, so be sure you understand what is in it and don’t get mired in “legalese.” Some firms offer third-party contract negotiation; they will assign an attorney to step in as an intermediary. Then again, most experts recommend against hiring a third-party negotiator, as this may increase the distance between you and your employer at a time probably best spent getting to know each other.

Maintain a Keen Eye

Specifics to look for in your new contract:

Work requirements. The employment agreement should visibly define your job responsibilities. Things to look for in your contract include the obligations of the physician, number of shifts or hours or weeks per year you are expected to work, call responsibilities, a census cap (if applicable), allotted vacation time, and continuing medical education time.

Compensation. The contract clearly should delineate how you will be paid. Some hospitalists are compensated solely via a salary; others are paid based on billing/productivity, while the majority are paid based on a combination of these methods (a base salary plus incentives). Be sure you understand the incentive and/or bonus structure of your salary. Practices basing incentives on physician productivity will incorporate your own billing practices and often is measured in relative value units (RVUs). In some settings, group incentives are based on quality targets set by the administration, such as the Joint Commission on the Accreditation of Healthcare Organi-­zations (JCAHO) core measure compliance, dictation timeliness, or patient/primary care physician satisfaction.

Benefits. In addition to your salary, you should see that your benefits are spelled out. The obvious benefits include medical, dental, and vision insurance, as well as a retirement savings plan. As discussed in the July 2008 issue of The Hospitalist, as demand for hospitalists continues to exceed supply, look for signing bonuses, coverage of relocation expenses, and the possibility of student loan payoff. Other important benefits include coverage of professional dues, CME allocation, and licensing and board examination fees.

Malpractice Insurance. This can be a complicated topic. In general, there are two major classes of malpractice insurance: an occurrence policy and a claims-made policy. In respect to an occurrence policy, any malpractice incident arising while the coverage was in place, regardless of when the claim was filed, will be covered even after you have stopped practicing under that policy. A claims-made policy, on the other hand, protects physicians for any covered claim, if they are insured when the claim is made. It does not cover malpractice claims filed after the physician cancels the malpractice policy, even if the claim is about an event that occurred while the physician was insured.

If you are offered a claims-made policy, require your employer to add tail coverage, which covers you after leaving the practice for any events occurred during employment. If you are unclear about any part of the group’s malpractice coverage, consider seeking legal advice.

Restrictive covenants. These are non-compete clauses often setting geographic and time restrictions of where and when a physician can practice in the event they leave the group. Though you never know what the future holds, this becomes relevant if you were to change jobs and work at an adjacent local facility or one in a nearby county. In general, hospitalists rarely carry a panel of patients, so an employer probably should not be concerned about hospitalists taking patients with them if/when they leave the practice. Be cautious of restrictive covenants found in your contract.

Ownership/Partnership. In some private groups, partnership will be offered after a preliminary employment period, usually one to two years. Look for your contract to state when and how partnership might be offered, and what the criteria to join are. This also is the time to ask others in the group to get a sense of how many associates are offered partnership and when this might happen.

Allowable Activities. Look for any restrictions regarding your activities outside normal clinical duties, such as teaching, research, or consulting for other firms. If such restrictions are in your contract, there may be specifications about whether income from such activities is yours or whether it is shared with the rest of the practice. TH

Bryan Huang, MD, assistant clinical professor, division of hospital medicine, University of California-San Diego Department of Medicine, Bhavin Patel, MD, hospitalist at Regions Hospital, HealthPartners Medical Group, St. Paul, Minn., Bijo Chacko, MD, hospitalist program medical director, Preferred Health Partners, New York City, and chair of SHM’s Young Physician Committee.

Within the next few months, many of you will have a new job as an attending hospitalist. As daunting as that may seem, now is the time to think about what you can do to ensure a smooth transition and successful beginning to your career.

Although residency prepared you to face the medical challenges ahead, here are 10 pointers that may help as you move to the next stage of your professional life.

1) Familiarize yourself with the licensing/credentialing process: Do not underestimate the amount of time it takes to get this paperwork approved—up to six months in some cases. Many new hires’ first days on the job are delayed because they didn’t complete this step. Check with state licensing boards for special requirements unique to that state. Also, every hospital has its own gauntlet of infectious disease, HIPAA, and information- technology hoops to jump through. Getting your applications in as early as possible puts you in position to begin on your planned start date and prevent last-minute catastrophes for your new program.

2) Gain valuable insight through observation: Study your current hospitalist group to gain perspective that will help in your new setting. All programs and hospitals operate differently and have room for quality/process improvement. Interview hospitalists, ask questions, and observe the workflow in your current hospital(s) to help in your new job.

3) Contemplate your career direction: Think strategically about your strengths and plans. Although you will learn an incredible amount about hospital medicine careers after you begin, having a sense of direction will help your new group and its leadership get you where you want to be. Making connections and making your goals known within your new program before you start will put your new career on the right path.

4) Seek mentors: Having mentors from your prior program and your new program is a key to a healthy and happy career. Choose people you respect and pick their brains about their careers, how they acquired their skills, and how they would advise you to do the same. Good mentors will help you for many years, and the most valuable may be the ones who have known you throughout your residency. Nurture and maintain these relationships even if you are moving on to new horizons. Inquire whether your new program has a mentorship structure or if your new group leader can recommend someone who shares common interests and goals.

5) Study SHM’s Core Com-petencies: Although you may have trepidation about your medical skills and knowledge as you move into uncharted waters, step back and relax. Know that you are prepared. That said, you can always learn more. One excellent resource is The Core Competencies in Hospital Medicine: A Framework for Curriculum Development (available on SHM’s Web site, www.hospitalmedicine.org). This is a set of standards with which programs can teach hospital medicine and you can learn the scope of expectations and competencies for someone in your position.

6) Understand the nuts and bolts of your new program: Although there are many things you will learn on the job, gain an appreciation for some of the following before your first day:

• Billing: If this is your responsibility, you need to learn a little about this before you start, preferably from one of your future colleagues.
• Reimbursement structure: Find out how your productivity is tracked and rewarded. You’d be amazed how variable this can be.
• Time allotment: How are administrative, research, committee and teaching time balanced against your clinical time?

7) Get to know your new hospital: Before hitting the wards it pays to do a little homework on your new workplace. Do you have access to a medical library, journals, UpToDate, or other online databases? If not, do you need to purchase this access on your own? Many programs have academic funds allotted so you can use those resources. Also, familiarize yourself with the local antibiogram, formularies, guidelines, and order sets. Most facilities have tools specific to their hospital. Know how these affect you in your new role. Prior to starting, you will also want to be sufficiently oriented to any computer systems and understand how they’re used for documentation and order entry, and for viewing lab, radiology, and microbiology results.

8) Shadow a hospitalist: Spending a few hours with someone during a typical hospitalist work day will give you an idea of the pace of the work, the layout of the hospital and floors, the medical and ancillary staff you will work with, and the patient population. This will prompt questions you hadn’t thought of previously.

9) Prepare for each specific role: Hospitalists wear many hats, including teaching attending, non-teaching attending, consultant, researcher, committee member, and hospital medicine leader. Each role carries specific responsibilities and expectations. Prior to each new role, train with someone who leads that service or knows the job intimately.

10) Comprehend your benefits: Does your employer have a retirement program? Do they match retirement contributions? How does the malpractice insurance work? A meeting with human resources will usually help you arrange your health, dental, malpractice, and disability insurance prior to your start date. TH

Dr. Chacko is chair of SHM’s young physician committee and the hospitalist program medical director for Preferred Health Partners in New York City. Dr. Markoff is an assistant professor of medicine and associate director of the hospitalist service at the Mount Sinai Hospital in New York City. Dr. Sliwka is a hospitalist and assistant professor of clinical medicine at the University of California, San Francisco Medical Center.

Within the next few months, many of you will have a new job as an attending hospitalist. As daunting as that may seem, now is the time to think about what you can do to ensure a smooth transition and successful beginning to your career.

Although residency prepared you to face the medical challenges ahead, here are 10 pointers that may help as you move to the next stage of your professional life.

1) Familiarize yourself with the licensing/credentialing process: Do not underestimate the amount of time it takes to get this paperwork approved—up to six months in some cases. Many new hires’ first days on the job are delayed because they didn’t complete this step. Check with state licensing boards for special requirements unique to that state. Also, every hospital has its own gauntlet of infectious disease, HIPAA, and information- technology hoops to jump through. Getting your applications in as early as possible puts you in position to begin on your planned start date and prevent last-minute catastrophes for your new program.

2) Gain valuable insight through observation: Study your current hospitalist group to gain perspective that will help in your new setting. All programs and hospitals operate differently and have room for quality/process improvement. Interview hospitalists, ask questions, and observe the workflow in your current hospital(s) to help in your new job.

3) Contemplate your career direction: Think strategically about your strengths and plans. Although you will learn an incredible amount about hospital medicine careers after you begin, having a sense of direction will help your new group and its leadership get you where you want to be. Making connections and making your goals known within your new program before you start will put your new career on the right path.

4) Seek mentors: Having mentors from your prior program and your new program is a key to a healthy and happy career. Choose people you respect and pick their brains about their careers, how they acquired their skills, and how they would advise you to do the same. Good mentors will help you for many years, and the most valuable may be the ones who have known you throughout your residency. Nurture and maintain these relationships even if you are moving on to new horizons. Inquire whether your new program has a mentorship structure or if your new group leader can recommend someone who shares common interests and goals.

5) Study SHM’s Core Com-petencies: Although you may have trepidation about your medical skills and knowledge as you move into uncharted waters, step back and relax. Know that you are prepared. That said, you can always learn more. One excellent resource is The Core Competencies in Hospital Medicine: A Framework for Curriculum Development (available on SHM’s Web site, www.hospitalmedicine.org). This is a set of standards with which programs can teach hospital medicine and you can learn the scope of expectations and competencies for someone in your position.

6) Understand the nuts and bolts of your new program: Although there are many things you will learn on the job, gain an appreciation for some of the following before your first day:

• Billing: If this is your responsibility, you need to learn a little about this before you start, preferably from one of your future colleagues.
• Reimbursement structure: Find out how your productivity is tracked and rewarded. You’d be amazed how variable this can be.
• Time allotment: How are administrative, research, committee and teaching time balanced against your clinical time?

7) Get to know your new hospital: Before hitting the wards it pays to do a little homework on your new workplace. Do you have access to a medical library, journals, UpToDate, or other online databases? If not, do you need to purchase this access on your own? Many programs have academic funds allotted so you can use those resources. Also, familiarize yourself with the local antibiogram, formularies, guidelines, and order sets. Most facilities have tools specific to their hospital. Know how these affect you in your new role. Prior to starting, you will also want to be sufficiently oriented to any computer systems and understand how they’re used for documentation and order entry, and for viewing lab, radiology, and microbiology results.

8) Shadow a hospitalist: Spending a few hours with someone during a typical hospitalist work day will give you an idea of the pace of the work, the layout of the hospital and floors, the medical and ancillary staff you will work with, and the patient population. This will prompt questions you hadn’t thought of previously.

9) Prepare for each specific role: Hospitalists wear many hats, including teaching attending, non-teaching attending, consultant, researcher, committee member, and hospital medicine leader. Each role carries specific responsibilities and expectations. Prior to each new role, train with someone who leads that service or knows the job intimately.

10) Comprehend your benefits: Does your employer have a retirement program? Do they match retirement contributions? How does the malpractice insurance work? A meeting with human resources will usually help you arrange your health, dental, malpractice, and disability insurance prior to your start date. TH

Dr. Chacko is chair of SHM’s young physician committee and the hospitalist program medical director for Preferred Health Partners in New York City. Dr. Markoff is an assistant professor of medicine and associate director of the hospitalist service at the Mount Sinai Hospital in New York City. Dr. Sliwka is a hospitalist and assistant professor of clinical medicine at the University of California, San Francisco Medical Center.

Within the next few months, many of you will have a new job as an attending hospitalist. As daunting as that may seem, now is the time to think about what you can do to ensure a smooth transition and successful beginning to your career.

Although residency prepared you to face the medical challenges ahead, here are 10 pointers that may help as you move to the next stage of your professional life.

1) Familiarize yourself with the licensing/credentialing process: Do not underestimate the amount of time it takes to get this paperwork approved—up to six months in some cases. Many new hires’ first days on the job are delayed because they didn’t complete this step. Check with state licensing boards for special requirements unique to that state. Also, every hospital has its own gauntlet of infectious disease, HIPAA, and information- technology hoops to jump through. Getting your applications in as early as possible puts you in position to begin on your planned start date and prevent last-minute catastrophes for your new program.

2) Gain valuable insight through observation: Study your current hospitalist group to gain perspective that will help in your new setting. All programs and hospitals operate differently and have room for quality/process improvement. Interview hospitalists, ask questions, and observe the workflow in your current hospital(s) to help in your new job.

3) Contemplate your career direction: Think strategically about your strengths and plans. Although you will learn an incredible amount about hospital medicine careers after you begin, having a sense of direction will help your new group and its leadership get you where you want to be. Making connections and making your goals known within your new program before you start will put your new career on the right path.

4) Seek mentors: Having mentors from your prior program and your new program is a key to a healthy and happy career. Choose people you respect and pick their brains about their careers, how they acquired their skills, and how they would advise you to do the same. Good mentors will help you for many years, and the most valuable may be the ones who have known you throughout your residency. Nurture and maintain these relationships even if you are moving on to new horizons. Inquire whether your new program has a mentorship structure or if your new group leader can recommend someone who shares common interests and goals.

5) Study SHM’s Core Com-petencies: Although you may have trepidation about your medical skills and knowledge as you move into uncharted waters, step back and relax. Know that you are prepared. That said, you can always learn more. One excellent resource is The Core Competencies in Hospital Medicine: A Framework for Curriculum Development (available on SHM’s Web site, www.hospitalmedicine.org). This is a set of standards with which programs can teach hospital medicine and you can learn the scope of expectations and competencies for someone in your position.

6) Understand the nuts and bolts of your new program: Although there are many things you will learn on the job, gain an appreciation for some of the following before your first day:

• Billing: If this is your responsibility, you need to learn a little about this before you start, preferably from one of your future colleagues.
• Reimbursement structure: Find out how your productivity is tracked and rewarded. You’d be amazed how variable this can be.
• Time allotment: How are administrative, research, committee and teaching time balanced against your clinical time?

7) Get to know your new hospital: Before hitting the wards it pays to do a little homework on your new workplace. Do you have access to a medical library, journals, UpToDate, or other online databases? If not, do you need to purchase this access on your own? Many programs have academic funds allotted so you can use those resources. Also, familiarize yourself with the local antibiogram, formularies, guidelines, and order sets. Most facilities have tools specific to their hospital. Know how these affect you in your new role. Prior to starting, you will also want to be sufficiently oriented to any computer systems and understand how they’re used for documentation and order entry, and for viewing lab, radiology, and microbiology results.

8) Shadow a hospitalist: Spending a few hours with someone during a typical hospitalist work day will give you an idea of the pace of the work, the layout of the hospital and floors, the medical and ancillary staff you will work with, and the patient population. This will prompt questions you hadn’t thought of previously.

9) Prepare for each specific role: Hospitalists wear many hats, including teaching attending, non-teaching attending, consultant, researcher, committee member, and hospital medicine leader. Each role carries specific responsibilities and expectations. Prior to each new role, train with someone who leads that service or knows the job intimately.

10) Comprehend your benefits: Does your employer have a retirement program? Do they match retirement contributions? How does the malpractice insurance work? A meeting with human resources will usually help you arrange your health, dental, malpractice, and disability insurance prior to your start date. TH

Dr. Chacko is chair of SHM’s young physician committee and the hospitalist program medical director for Preferred Health Partners in New York City. Dr. Markoff is an assistant professor of medicine and associate director of the hospitalist service at the Mount Sinai Hospital in New York City. Dr. Sliwka is a hospitalist and assistant professor of clinical medicine at the University of California, San Francisco Medical Center.

Retrospective Study of Symptoms in Post-Discharge Patients

Epstein K, Juarez E, Loya K, et al. Frequency of new or worsening symptoms in the posthospitalization period. J Hosp Med. March/April 2007;2(2):58-68.

As hospital stays shorten and acuity rises, patients often are discharged with complex instructions and discharge plans including home health services, physical therapy, hospice service, antibiotic infusions, and follow-up appointments. The potential for new or progressive symptoms in the days following discharge is an important parameter in assessing whether our planning is safe and effective.

The researchers in this study investigated the post-discharge period using a retrospective analysis of new or worsening symptoms within two to five days of hospital discharge among 15,767 patients surveyed between May 1 and Oct. 31, 2003. Patients were all under the care of hospitalists employed by IPC, a large private hospitalist group based in North Hollywood, Calif. Total discharges from which this cohort was selected numbered 48,236.

Staff with medical backgrounds conducted a scripted survey by phone. Licensed nursing personnel contacted those patients whose answers to initial questions suggested they were at high risk for postdischarge complications. A five-point Likert scale was used so patients could rate their overall health status in addition to specific symptomatology ranging from abdominal pain to bleeding. Other questions targeted pick-up and administration of prescribed medications, insulin regimen adherence, and implementation of home health services.

Among all patients discharged, 32.7% were contacted within two days of discharge. The mean age was 60.1 years, and 57% were female. Ethnicity and socioeconomic status were not reported. Medicare and HMOs were the most common type of insurance. Of the 15,767 patients contacted, 11.9% reported symptoms that were new or worsening since discharge; of this subgroup, 64% had new symptoms whereas 36% had “worse” symptoms.

Women were more likely than men to report new or worsening symptoms, and patients who rated themselves as having a poor health status were more likely to have new or worsening symptoms. Younger patients were less likely to report new or worsening symptoms, particularly younger men. Those with new or worse symptoms were slightly more likely to have made a follow-up appointment but also more likely to have a problem with their medications. Interestingly, there was no correlation between self-rated health status and reported severity of illness based on the diagnosis related group (DRG) score. Patients discharged with a DRG of chest pain were less likely to report symptoms than all other patients.

The authors acknowledge the low response rate (32.7%) relative to the 48,236 discharges during the study period. Logistic challenges, resource limitations, and erroneous contact information precluded successful contact for the remainder of patients. The magnitude of this exclusion effect essentially precludes statistically valid extrapolation to the inception cohort (all discharges). For example, in a sensitivity analysis where all the excluded patients are assumed to have developed new or worsening symptoms, the actual rate overall would have been 71%. If none developed new or worsening symptoms, that rate would be 3.8%. The rate for the inception cohort may or may not approximate the 11.9% found among the studied patients. There is insufficient evidence to determine whether the studied cohort reflects the entire population of discharged patients.

To their credit, no such analysis or interpretation is claimed or intended by the authors, and the information derived from the included cohort nonetheless provides interesting and important descriptive data.

Ethnicity and cultural factors were not taken into consideration. One might postulate that language barriers could affect compliance and symptom reporting. Day-of-the-week and holiday status also were not reported with regard to discharge. It would be interesting and useful to know whether access to pharmacy and other resources varied in this regard and whether symptom reporting was affected by such timing.

In the final analysis, this study suggests hospitalists remain alert to possible problems that might develop during the vulnerable first few days following discharge. It reminds us to advise patients how to receive prompt and knowledgeable medical advice from someone familiar with their hospital care prior to their first scheduled follow-up.

Based on the reported rate of new or worsening symptoms, should a post-discharge clinic be part of hospitalists’ scope of practice, at least for selected patients? Can subsets of patients who would benefit most from such intervention be identified? These and many more questions are raised by this study. We look forward to further research into the best process for ensuring optimal outcomes in the immediate post-discharge period.

Rosiglitazone’s Effect on MI Risk in Diabetes Patients

Nissen SE, Wolski K. Effect of rosiglitazone on the risk of myocardial infarction and death from cardiovascular causes. N Engl J Med. 2007 June 14;356(24):2457-2471.

Cardiovascular causes account for more than 65% of deaths in diabetic patients. Rosiglitazone—a thiazolidinedione-class drug—has been broadly used in diabetes, but its effect on cardiovascular morbidity and mortality has not been conclusively determined. The authors initiated this meta-analysis to determine the effect of rosiglitazone on the risk of myocardial infarction (MI) and death from cardiovascular causes in diabetics.

The meta-analysis included 42 trials from three data sources. Forty trials were obtained from the Food and Drug Administration (FDA) Web site and the GlaxoSmithKline clinical trials registry. The third data source comprised two recent large, well-known trials: the Diabetes Reduction Assessment with Ramipril and Rosiglitazone Medication (DREAM) and the A Diabetes Outcome Prevention Trial (ADOPT).1-2 The authors’ inclusion criteria were a study with a duration of more than 24 weeks, the use of a randomized control group not receiving rosiglitazone (placebo or comparator drug), and the availability of outcome data for MI and death from cardiovascular causes.

The studies included 15,560 patients randomly assigned to regimens that included rosiglitazone and 12,283 patients to comparator groups that did not include rosiglitazone.

The authors reviewed the data summaries of the 42 trials and tabulated adverse events (not reported as outcomes) of MI and death from cardiovascular causes. Hazard ratios could not be calculated since time-to-event data were lacking. Summary data also precluded the ability to determine whether the same patient suffered both an MI and death from cardiovascular causes.

Results of the authors’ statistical analyses included odds ratios and 95% confidence intervals to assess the risk associated with the rosiglitazone group as well as the subgroups of metformin, sulfonylurea, insulin, and placebo versus rosiglitazone.

The authors tabulated 86 MIs and 39 unadjudicated deaths from cardiovascular causes in the rosiglitazone group, and 72 MIs plus 22 deaths from cardiovascular causes in the control group.

The main conclusion was that rosiglitazone was associated with a statistically significant increase in the risk of MI (odds ratio 1.43, 95% confidence interval 1.03 to 1.98, p=0.03), but was not associated with a statistically significant increase in the risk of death from cardiovascular causes (odds ratio 1.64, 95% confidence interval 0.98 to 2.74, p=0.06).

Additionally, there were no statistical differences between rosiglitazone versus placebo or the individual antidiabetics in the subanalyses.

The authors have recognized the following major limitations in this meta-analysis:

• The low rate of MI is 0.55% (86 of 15,560 cases) in the rosiglitazone group and 0.59% (72 of 12,283 cases) in the control group. The odds ratio of 1.43 was statistically significant in the rosiglitazone group, although the event rate was higher in the control group. The risk of cardiovascular death was not significant, though a trend toward a higher death rate is noted;
• The lack of source data did not allow the use of time event analysis including hazard ratios;
• The definition of MI was unavailable; and
• MI and cardiovascular events were recorded in the trials as adverse events, not outcomes. Therefore, deaths from the latter were unadjudicated.

The authors suggested that the potential mechanism for increased MI in the rosiglitazone group could be its known effects on increasing low-density lipoproteins (LDL), precipitating congestive heart failure and reducing hemoglobin levels.

Rosiglitazone is one of two peroxisome proliferation activated receptor y (PPAR-y) agonists licensed for use in the United States; the other is pioglitazone. The third drug was troglitazone; it was taken off the market in March of 2000 due to hepatotoxicity.

The PPAR-y agonists decrease plasma glycemia by increasing insulin sensitivity in the peripheral tissues. These drugs have complex physiologic effects in activating and suppressing multiple genes, with most target genes being unknown. The observed side effects with rosiglitazone are not necessarily a class effect. Pioglitazone showed a trend toward reducing triglycerides and cardiovascular events, including MI and CVA, in a prospective, randomized trial called Prospective Pioglitazone Clinical Trial in Macrovascular Events (PROACTIVE).

This meta-analysis precipitated an interim analysis of the ongoing Rosiglitazone Evaluated for Cardiovascular Outcomes and Regulation of Glycemia in Diabetes (RECORD) trial.3 The RECORD trial is a randomized, open-label, multicenter, non-inferiority trial of 4,427 patients; 2,220 received add-on rosiglitazone, and 2,227 received a combination of metformin plus sulfonylurea (control group). The primary end point was hospitalization or death from cardiovascular causes. Interim findings were inconclusive for the rosiglitazone group. There was also no evidence of any increase in death from cardiovascular causes or all causes. However, rosiglitazone was found to be associated with an increased risk of congestive heart failure. The data were insufficient to determine whether the drug was associated with increased MI risk.

This important meta-analysis raises concerns about the association of rosiglitazone with cardiovascular events—but do not consider it definitive. For now, patients with comparable alternatives to rosiglitazone (indeed all patients on this medication) should be advised of the undetermined safety concerns. For those who consider rosiglitazone a compelling choice, abrupt discontinuation on the basis of this study may be premature.

Finally, we need to remain cognizant of the proven negative side effects of rosiglitazone—it increases fracture risks in women, precipitates congestive heart failure, increases LDL, and decreases hemoglobin levels. We should consider alternative anti-hyperglycemic agents in selected patients at risk until there are solid data from large randomized control trials with rosiglitazone that pre-empt its use altogether.

References

1. Gerstein HC, Yusuf S, Bosch J, et al. Effect of rosiglitazone on the frequency of diabetes in patients with impaired glucose tolerance or impaired fasting glucose: a randomized controlled trial. Lancet 2006 Sep 23; 368(9547):1096-1105.
2. Kahn SE, Haffner SM, Heise MA, et al; ADOPT Study Group. Glycemic durability of rosiglitazone, metformin, or glyburide monotherapy. N Engl J Med. 2006 Dec 7;355(23):2427-2443.
3. Home PD, Pocock SJ, Beck-Nielsen H, et al. Rosiglitazone evaluated for cardiac outcomes and regulation of glycemia in diabetes (RECORD): study design and protocol. Diabetologia. 2005;48:1726-1735.

Statins and Sepsis in Dialysis Patients

Gupta R, Plantinga LC, Fink NE, et al. Statin use and hospitalization for sepsis in patients with chronic kidney disease. JAMA. 2007 Apr 4;297(13):1455-1464.

Epidemiological data has revealed an increase in the rate of sepsis in the U.S. during the past two decades.1 In individuals with chronic kidney disease who are on dialysis, sepsis is a significant cause of morbidity and mortality. Various studies have looked at risk factors associated with septicemia in patients with chronic kidney disease; however, no preventive treatments have been identified.

Recent research has shown the use of statins has been associated with a decreased rate of sepsis and improved sepsis outcomes. The authors of this study investigated whether statin use may help reduce the incidence of sepsis in patients with chronic kidney disease on dialysis.

This prospective cohort study enrolled 1,041 participants attending dialysis clinics from October 1995 to June 1998, with a follow-up through Jan. 1, 2005. Statin use at baseline was determined by review of medical records. The primary outcome was hospitalization for sepsis, indicated by hospital data from the U.S. Renal Data System (mean follow-up 3.4 years).

The association of statin use and sepsis was assessed using two analyses. A multivariate regression analysis was performed on the entire cohort, and adjustments were made for potential confounders. An analysis was performed on a sub-cohort comparing sepsis rates in statin users with a control group identified through the likelihood of having been prescribed a statin (propensity matching).

There were 303 hospitalizations for sepsis among the 1,041 patients enrolled, with 14% of participants receiving a statin at baseline. The crude incidence rate of sepsis was 41/1,000 patient-years among statin users compared with 110/1,000 patient-years in the control group (p<0.001). The fully adjusted incidence ratio for sepsis among statin users versus nonusers was 0.38, or 62% lower among statin users.

In the propensity-matched subcohort group, there were 54 hospitalizations during follow-up. The relative risk of sepsis was 0.24 (95% confidence interval, 0.11-0.49) for statin users compared with nonusers.

A strong and independent association exists between statin use and reduced incidence of sepsis in chronic kidney disease patients. This association remained statistically significant after controlling for potential confounding. Why the statins might have this effect is not definitively known.

This national study further demonstrates the potential protective effect of statins on the occurrence of sepsis, which has been observed in previous research in a non-renal population. The author mentions that this is the first study to show a strong and significant effect of a medication administered long term on lower rates of sepsis among patients with chronic kidney disease.

Because this is an observational study, it is limited due to lack of randomization. As such, this study cannot prove causality. Further limitations include the assessment of patient and treatment factors at baseline, which can lead to a misclassification of factors that change over time. It is important to point out the study was dependent on U.S. Renal Data System and Medicare data to determine outcome, and the use of their ICD-9 coding information may have resulted in decreased reporting of sepsis.

Still, the relevant results of this investigation warrant further examination of statins and the prevention of sepsis in a prospective randomized trial. TH

Reference

1. Sarnak MJ, Jaber BL. Mortality caused by sepsis in patients with end-stage renal disease compared with the general population. Kidney Int. 2000 Oct;58(4):1758-1764.

Retrospective Study of Symptoms in Post-Discharge Patients

Epstein K, Juarez E, Loya K, et al. Frequency of new or worsening symptoms in the posthospitalization period. J Hosp Med. March/April 2007;2(2):58-68.

As hospital stays shorten and acuity rises, patients often are discharged with complex instructions and discharge plans including home health services, physical therapy, hospice service, antibiotic infusions, and follow-up appointments. The potential for new or progressive symptoms in the days following discharge is an important parameter in assessing whether our planning is safe and effective.

The researchers in this study investigated the post-discharge period using a retrospective analysis of new or worsening symptoms within two to five days of hospital discharge among 15,767 patients surveyed between May 1 and Oct. 31, 2003. Patients were all under the care of hospitalists employed by IPC, a large private hospitalist group based in North Hollywood, Calif. Total discharges from which this cohort was selected numbered 48,236.

Staff with medical backgrounds conducted a scripted survey by phone. Licensed nursing personnel contacted those patients whose answers to initial questions suggested they were at high risk for postdischarge complications. A five-point Likert scale was used so patients could rate their overall health status in addition to specific symptomatology ranging from abdominal pain to bleeding. Other questions targeted pick-up and administration of prescribed medications, insulin regimen adherence, and implementation of home health services.

Among all patients discharged, 32.7% were contacted within two days of discharge. The mean age was 60.1 years, and 57% were female. Ethnicity and socioeconomic status were not reported. Medicare and HMOs were the most common type of insurance. Of the 15,767 patients contacted, 11.9% reported symptoms that were new or worsening since discharge; of this subgroup, 64% had new symptoms whereas 36% had “worse” symptoms.

Women were more likely than men to report new or worsening symptoms, and patients who rated themselves as having a poor health status were more likely to have new or worsening symptoms. Younger patients were less likely to report new or worsening symptoms, particularly younger men. Those with new or worse symptoms were slightly more likely to have made a follow-up appointment but also more likely to have a problem with their medications. Interestingly, there was no correlation between self-rated health status and reported severity of illness based on the diagnosis related group (DRG) score. Patients discharged with a DRG of chest pain were less likely to report symptoms than all other patients.

The authors acknowledge the low response rate (32.7%) relative to the 48,236 discharges during the study period. Logistic challenges, resource limitations, and erroneous contact information precluded successful contact for the remainder of patients. The magnitude of this exclusion effect essentially precludes statistically valid extrapolation to the inception cohort (all discharges). For example, in a sensitivity analysis where all the excluded patients are assumed to have developed new or worsening symptoms, the actual rate overall would have been 71%. If none developed new or worsening symptoms, that rate would be 3.8%. The rate for the inception cohort may or may not approximate the 11.9% found among the studied patients. There is insufficient evidence to determine whether the studied cohort reflects the entire population of discharged patients.

To their credit, no such analysis or interpretation is claimed or intended by the authors, and the information derived from the included cohort nonetheless provides interesting and important descriptive data.

Ethnicity and cultural factors were not taken into consideration. One might postulate that language barriers could affect compliance and symptom reporting. Day-of-the-week and holiday status also were not reported with regard to discharge. It would be interesting and useful to know whether access to pharmacy and other resources varied in this regard and whether symptom reporting was affected by such timing.

In the final analysis, this study suggests hospitalists remain alert to possible problems that might develop during the vulnerable first few days following discharge. It reminds us to advise patients how to receive prompt and knowledgeable medical advice from someone familiar with their hospital care prior to their first scheduled follow-up.

Based on the reported rate of new or worsening symptoms, should a post-discharge clinic be part of hospitalists’ scope of practice, at least for selected patients? Can subsets of patients who would benefit most from such intervention be identified? These and many more questions are raised by this study. We look forward to further research into the best process for ensuring optimal outcomes in the immediate post-discharge period.

Rosiglitazone’s Effect on MI Risk in Diabetes Patients

Nissen SE, Wolski K. Effect of rosiglitazone on the risk of myocardial infarction and death from cardiovascular causes. N Engl J Med. 2007 June 14;356(24):2457-2471.

Cardiovascular causes account for more than 65% of deaths in diabetic patients. Rosiglitazone—a thiazolidinedione-class drug—has been broadly used in diabetes, but its effect on cardiovascular morbidity and mortality has not been conclusively determined. The authors initiated this meta-analysis to determine the effect of rosiglitazone on the risk of myocardial infarction (MI) and death from cardiovascular causes in diabetics.

The meta-analysis included 42 trials from three data sources. Forty trials were obtained from the Food and Drug Administration (FDA) Web site and the GlaxoSmithKline clinical trials registry. The third data source comprised two recent large, well-known trials: the Diabetes Reduction Assessment with Ramipril and Rosiglitazone Medication (DREAM) and the A Diabetes Outcome Prevention Trial (ADOPT).1-2 The authors’ inclusion criteria were a study with a duration of more than 24 weeks, the use of a randomized control group not receiving rosiglitazone (placebo or comparator drug), and the availability of outcome data for MI and death from cardiovascular causes.

The studies included 15,560 patients randomly assigned to regimens that included rosiglitazone and 12,283 patients to comparator groups that did not include rosiglitazone.

The authors reviewed the data summaries of the 42 trials and tabulated adverse events (not reported as outcomes) of MI and death from cardiovascular causes. Hazard ratios could not be calculated since time-to-event data were lacking. Summary data also precluded the ability to determine whether the same patient suffered both an MI and death from cardiovascular causes.

Results of the authors’ statistical analyses included odds ratios and 95% confidence intervals to assess the risk associated with the rosiglitazone group as well as the subgroups of metformin, sulfonylurea, insulin, and placebo versus rosiglitazone.

The authors tabulated 86 MIs and 39 unadjudicated deaths from cardiovascular causes in the rosiglitazone group, and 72 MIs plus 22 deaths from cardiovascular causes in the control group.

The main conclusion was that rosiglitazone was associated with a statistically significant increase in the risk of MI (odds ratio 1.43, 95% confidence interval 1.03 to 1.98, p=0.03), but was not associated with a statistically significant increase in the risk of death from cardiovascular causes (odds ratio 1.64, 95% confidence interval 0.98 to 2.74, p=0.06).

Additionally, there were no statistical differences between rosiglitazone versus placebo or the individual antidiabetics in the subanalyses.

The authors have recognized the following major limitations in this meta-analysis:

• The low rate of MI is 0.55% (86 of 15,560 cases) in the rosiglitazone group and 0.59% (72 of 12,283 cases) in the control group. The odds ratio of 1.43 was statistically significant in the rosiglitazone group, although the event rate was higher in the control group. The risk of cardiovascular death was not significant, though a trend toward a higher death rate is noted;
• The lack of source data did not allow the use of time event analysis including hazard ratios;
• The definition of MI was unavailable; and
• MI and cardiovascular events were recorded in the trials as adverse events, not outcomes. Therefore, deaths from the latter were unadjudicated.

The authors suggested that the potential mechanism for increased MI in the rosiglitazone group could be its known effects on increasing low-density lipoproteins (LDL), precipitating congestive heart failure and reducing hemoglobin levels.

Rosiglitazone is one of two peroxisome proliferation activated receptor y (PPAR-y) agonists licensed for use in the United States; the other is pioglitazone. The third drug was troglitazone; it was taken off the market in March of 2000 due to hepatotoxicity.

The PPAR-y agonists decrease plasma glycemia by increasing insulin sensitivity in the peripheral tissues. These drugs have complex physiologic effects in activating and suppressing multiple genes, with most target genes being unknown. The observed side effects with rosiglitazone are not necessarily a class effect. Pioglitazone showed a trend toward reducing triglycerides and cardiovascular events, including MI and CVA, in a prospective, randomized trial called Prospective Pioglitazone Clinical Trial in Macrovascular Events (PROACTIVE).

This meta-analysis precipitated an interim analysis of the ongoing Rosiglitazone Evaluated for Cardiovascular Outcomes and Regulation of Glycemia in Diabetes (RECORD) trial.3 The RECORD trial is a randomized, open-label, multicenter, non-inferiority trial of 4,427 patients; 2,220 received add-on rosiglitazone, and 2,227 received a combination of metformin plus sulfonylurea (control group). The primary end point was hospitalization or death from cardiovascular causes. Interim findings were inconclusive for the rosiglitazone group. There was also no evidence of any increase in death from cardiovascular causes or all causes. However, rosiglitazone was found to be associated with an increased risk of congestive heart failure. The data were insufficient to determine whether the drug was associated with increased MI risk.

This important meta-analysis raises concerns about the association of rosiglitazone with cardiovascular events—but do not consider it definitive. For now, patients with comparable alternatives to rosiglitazone (indeed all patients on this medication) should be advised of the undetermined safety concerns. For those who consider rosiglitazone a compelling choice, abrupt discontinuation on the basis of this study may be premature.

Finally, we need to remain cognizant of the proven negative side effects of rosiglitazone—it increases fracture risks in women, precipitates congestive heart failure, increases LDL, and decreases hemoglobin levels. We should consider alternative anti-hyperglycemic agents in selected patients at risk until there are solid data from large randomized control trials with rosiglitazone that pre-empt its use altogether.

References

1. Gerstein HC, Yusuf S, Bosch J, et al. Effect of rosiglitazone on the frequency of diabetes in patients with impaired glucose tolerance or impaired fasting glucose: a randomized controlled trial. Lancet 2006 Sep 23; 368(9547):1096-1105.
2. Kahn SE, Haffner SM, Heise MA, et al; ADOPT Study Group. Glycemic durability of rosiglitazone, metformin, or glyburide monotherapy. N Engl J Med. 2006 Dec 7;355(23):2427-2443.
3. Home PD, Pocock SJ, Beck-Nielsen H, et al. Rosiglitazone evaluated for cardiac outcomes and regulation of glycemia in diabetes (RECORD): study design and protocol. Diabetologia. 2005;48:1726-1735.

Statins and Sepsis in Dialysis Patients

Gupta R, Plantinga LC, Fink NE, et al. Statin use and hospitalization for sepsis in patients with chronic kidney disease. JAMA. 2007 Apr 4;297(13):1455-1464.

Epidemiological data has revealed an increase in the rate of sepsis in the U.S. during the past two decades.1 In individuals with chronic kidney disease who are on dialysis, sepsis is a significant cause of morbidity and mortality. Various studies have looked at risk factors associated with septicemia in patients with chronic kidney disease; however, no preventive treatments have been identified.

Recent research has shown the use of statins has been associated with a decreased rate of sepsis and improved sepsis outcomes. The authors of this study investigated whether statin use may help reduce the incidence of sepsis in patients with chronic kidney disease on dialysis.

This prospective cohort study enrolled 1,041 participants attending dialysis clinics from October 1995 to June 1998, with a follow-up through Jan. 1, 2005. Statin use at baseline was determined by review of medical records. The primary outcome was hospitalization for sepsis, indicated by hospital data from the U.S. Renal Data System (mean follow-up 3.4 years).

The association of statin use and sepsis was assessed using two analyses. A multivariate regression analysis was performed on the entire cohort, and adjustments were made for potential confounders. An analysis was performed on a sub-cohort comparing sepsis rates in statin users with a control group identified through the likelihood of having been prescribed a statin (propensity matching).

There were 303 hospitalizations for sepsis among the 1,041 patients enrolled, with 14% of participants receiving a statin at baseline. The crude incidence rate of sepsis was 41/1,000 patient-years among statin users compared with 110/1,000 patient-years in the control group (p<0.001). The fully adjusted incidence ratio for sepsis among statin users versus nonusers was 0.38, or 62% lower among statin users.

In the propensity-matched subcohort group, there were 54 hospitalizations during follow-up. The relative risk of sepsis was 0.24 (95% confidence interval, 0.11-0.49) for statin users compared with nonusers.

A strong and independent association exists between statin use and reduced incidence of sepsis in chronic kidney disease patients. This association remained statistically significant after controlling for potential confounding. Why the statins might have this effect is not definitively known.

This national study further demonstrates the potential protective effect of statins on the occurrence of sepsis, which has been observed in previous research in a non-renal population. The author mentions that this is the first study to show a strong and significant effect of a medication administered long term on lower rates of sepsis among patients with chronic kidney disease.

Because this is an observational study, it is limited due to lack of randomization. As such, this study cannot prove causality. Further limitations include the assessment of patient and treatment factors at baseline, which can lead to a misclassification of factors that change over time. It is important to point out the study was dependent on U.S. Renal Data System and Medicare data to determine outcome, and the use of their ICD-9 coding information may have resulted in decreased reporting of sepsis.

Still, the relevant results of this investigation warrant further examination of statins and the prevention of sepsis in a prospective randomized trial. TH

Reference

1. Sarnak MJ, Jaber BL. Mortality caused by sepsis in patients with end-stage renal disease compared with the general population. Kidney Int. 2000 Oct;58(4):1758-1764.

Retrospective Study of Symptoms in Post-Discharge Patients

Epstein K, Juarez E, Loya K, et al. Frequency of new or worsening symptoms in the posthospitalization period. J Hosp Med. March/April 2007;2(2):58-68.

As hospital stays shorten and acuity rises, patients often are discharged with complex instructions and discharge plans including home health services, physical therapy, hospice service, antibiotic infusions, and follow-up appointments. The potential for new or progressive symptoms in the days following discharge is an important parameter in assessing whether our planning is safe and effective.

The researchers in this study investigated the post-discharge period using a retrospective analysis of new or worsening symptoms within two to five days of hospital discharge among 15,767 patients surveyed between May 1 and Oct. 31, 2003. Patients were all under the care of hospitalists employed by IPC, a large private hospitalist group based in North Hollywood, Calif. Total discharges from which this cohort was selected numbered 48,236.

Staff with medical backgrounds conducted a scripted survey by phone. Licensed nursing personnel contacted those patients whose answers to initial questions suggested they were at high risk for postdischarge complications. A five-point Likert scale was used so patients could rate their overall health status in addition to specific symptomatology ranging from abdominal pain to bleeding. Other questions targeted pick-up and administration of prescribed medications, insulin regimen adherence, and implementation of home health services.

Among all patients discharged, 32.7% were contacted within two days of discharge. The mean age was 60.1 years, and 57% were female. Ethnicity and socioeconomic status were not reported. Medicare and HMOs were the most common type of insurance. Of the 15,767 patients contacted, 11.9% reported symptoms that were new or worsening since discharge; of this subgroup, 64% had new symptoms whereas 36% had “worse” symptoms.

Women were more likely than men to report new or worsening symptoms, and patients who rated themselves as having a poor health status were more likely to have new or worsening symptoms. Younger patients were less likely to report new or worsening symptoms, particularly younger men. Those with new or worse symptoms were slightly more likely to have made a follow-up appointment but also more likely to have a problem with their medications. Interestingly, there was no correlation between self-rated health status and reported severity of illness based on the diagnosis related group (DRG) score. Patients discharged with a DRG of chest pain were less likely to report symptoms than all other patients.

The authors acknowledge the low response rate (32.7%) relative to the 48,236 discharges during the study period. Logistic challenges, resource limitations, and erroneous contact information precluded successful contact for the remainder of patients. The magnitude of this exclusion effect essentially precludes statistically valid extrapolation to the inception cohort (all discharges). For example, in a sensitivity analysis where all the excluded patients are assumed to have developed new or worsening symptoms, the actual rate overall would have been 71%. If none developed new or worsening symptoms, that rate would be 3.8%. The rate for the inception cohort may or may not approximate the 11.9% found among the studied patients. There is insufficient evidence to determine whether the studied cohort reflects the entire population of discharged patients.

To their credit, no such analysis or interpretation is claimed or intended by the authors, and the information derived from the included cohort nonetheless provides interesting and important descriptive data.

Ethnicity and cultural factors were not taken into consideration. One might postulate that language barriers could affect compliance and symptom reporting. Day-of-the-week and holiday status also were not reported with regard to discharge. It would be interesting and useful to know whether access to pharmacy and other resources varied in this regard and whether symptom reporting was affected by such timing.

In the final analysis, this study suggests hospitalists remain alert to possible problems that might develop during the vulnerable first few days following discharge. It reminds us to advise patients how to receive prompt and knowledgeable medical advice from someone familiar with their hospital care prior to their first scheduled follow-up.

Based on the reported rate of new or worsening symptoms, should a post-discharge clinic be part of hospitalists’ scope of practice, at least for selected patients? Can subsets of patients who would benefit most from such intervention be identified? These and many more questions are raised by this study. We look forward to further research into the best process for ensuring optimal outcomes in the immediate post-discharge period.

Rosiglitazone’s Effect on MI Risk in Diabetes Patients

Nissen SE, Wolski K. Effect of rosiglitazone on the risk of myocardial infarction and death from cardiovascular causes. N Engl J Med. 2007 June 14;356(24):2457-2471.

Cardiovascular causes account for more than 65% of deaths in diabetic patients. Rosiglitazone—a thiazolidinedione-class drug—has been broadly used in diabetes, but its effect on cardiovascular morbidity and mortality has not been conclusively determined. The authors initiated this meta-analysis to determine the effect of rosiglitazone on the risk of myocardial infarction (MI) and death from cardiovascular causes in diabetics.

The meta-analysis included 42 trials from three data sources. Forty trials were obtained from the Food and Drug Administration (FDA) Web site and the GlaxoSmithKline clinical trials registry. The third data source comprised two recent large, well-known trials: the Diabetes Reduction Assessment with Ramipril and Rosiglitazone Medication (DREAM) and the A Diabetes Outcome Prevention Trial (ADOPT).1-2 The authors’ inclusion criteria were a study with a duration of more than 24 weeks, the use of a randomized control group not receiving rosiglitazone (placebo or comparator drug), and the availability of outcome data for MI and death from cardiovascular causes.

The studies included 15,560 patients randomly assigned to regimens that included rosiglitazone and 12,283 patients to comparator groups that did not include rosiglitazone.

The authors reviewed the data summaries of the 42 trials and tabulated adverse events (not reported as outcomes) of MI and death from cardiovascular causes. Hazard ratios could not be calculated since time-to-event data were lacking. Summary data also precluded the ability to determine whether the same patient suffered both an MI and death from cardiovascular causes.

Results of the authors’ statistical analyses included odds ratios and 95% confidence intervals to assess the risk associated with the rosiglitazone group as well as the subgroups of metformin, sulfonylurea, insulin, and placebo versus rosiglitazone.

The authors tabulated 86 MIs and 39 unadjudicated deaths from cardiovascular causes in the rosiglitazone group, and 72 MIs plus 22 deaths from cardiovascular causes in the control group.

The main conclusion was that rosiglitazone was associated with a statistically significant increase in the risk of MI (odds ratio 1.43, 95% confidence interval 1.03 to 1.98, p=0.03), but was not associated with a statistically significant increase in the risk of death from cardiovascular causes (odds ratio 1.64, 95% confidence interval 0.98 to 2.74, p=0.06).

Additionally, there were no statistical differences between rosiglitazone versus placebo or the individual antidiabetics in the subanalyses.

The authors have recognized the following major limitations in this meta-analysis:

• The low rate of MI is 0.55% (86 of 15,560 cases) in the rosiglitazone group and 0.59% (72 of 12,283 cases) in the control group. The odds ratio of 1.43 was statistically significant in the rosiglitazone group, although the event rate was higher in the control group. The risk of cardiovascular death was not significant, though a trend toward a higher death rate is noted;
• The lack of source data did not allow the use of time event analysis including hazard ratios;
• The definition of MI was unavailable; and
• MI and cardiovascular events were recorded in the trials as adverse events, not outcomes. Therefore, deaths from the latter were unadjudicated.

The authors suggested that the potential mechanism for increased MI in the rosiglitazone group could be its known effects on increasing low-density lipoproteins (LDL), precipitating congestive heart failure and reducing hemoglobin levels.

Rosiglitazone is one of two peroxisome proliferation activated receptor y (PPAR-y) agonists licensed for use in the United States; the other is pioglitazone. The third drug was troglitazone; it was taken off the market in March of 2000 due to hepatotoxicity.

The PPAR-y agonists decrease plasma glycemia by increasing insulin sensitivity in the peripheral tissues. These drugs have complex physiologic effects in activating and suppressing multiple genes, with most target genes being unknown. The observed side effects with rosiglitazone are not necessarily a class effect. Pioglitazone showed a trend toward reducing triglycerides and cardiovascular events, including MI and CVA, in a prospective, randomized trial called Prospective Pioglitazone Clinical Trial in Macrovascular Events (PROACTIVE).

This meta-analysis precipitated an interim analysis of the ongoing Rosiglitazone Evaluated for Cardiovascular Outcomes and Regulation of Glycemia in Diabetes (RECORD) trial.3 The RECORD trial is a randomized, open-label, multicenter, non-inferiority trial of 4,427 patients; 2,220 received add-on rosiglitazone, and 2,227 received a combination of metformin plus sulfonylurea (control group). The primary end point was hospitalization or death from cardiovascular causes. Interim findings were inconclusive for the rosiglitazone group. There was also no evidence of any increase in death from cardiovascular causes or all causes. However, rosiglitazone was found to be associated with an increased risk of congestive heart failure. The data were insufficient to determine whether the drug was associated with increased MI risk.

This important meta-analysis raises concerns about the association of rosiglitazone with cardiovascular events—but do not consider it definitive. For now, patients with comparable alternatives to rosiglitazone (indeed all patients on this medication) should be advised of the undetermined safety concerns. For those who consider rosiglitazone a compelling choice, abrupt discontinuation on the basis of this study may be premature.

Finally, we need to remain cognizant of the proven negative side effects of rosiglitazone—it increases fracture risks in women, precipitates congestive heart failure, increases LDL, and decreases hemoglobin levels. We should consider alternative anti-hyperglycemic agents in selected patients at risk until there are solid data from large randomized control trials with rosiglitazone that pre-empt its use altogether.

References

1. Gerstein HC, Yusuf S, Bosch J, et al. Effect of rosiglitazone on the frequency of diabetes in patients with impaired glucose tolerance or impaired fasting glucose: a randomized controlled trial. Lancet 2006 Sep 23; 368(9547):1096-1105.
2. Kahn SE, Haffner SM, Heise MA, et al; ADOPT Study Group. Glycemic durability of rosiglitazone, metformin, or glyburide monotherapy. N Engl J Med. 2006 Dec 7;355(23):2427-2443.
3. Home PD, Pocock SJ, Beck-Nielsen H, et al. Rosiglitazone evaluated for cardiac outcomes and regulation of glycemia in diabetes (RECORD): study design and protocol. Diabetologia. 2005;48:1726-1735.

Statins and Sepsis in Dialysis Patients

Gupta R, Plantinga LC, Fink NE, et al. Statin use and hospitalization for sepsis in patients with chronic kidney disease. JAMA. 2007 Apr 4;297(13):1455-1464.

Epidemiological data has revealed an increase in the rate of sepsis in the U.S. during the past two decades.1 In individuals with chronic kidney disease who are on dialysis, sepsis is a significant cause of morbidity and mortality. Various studies have looked at risk factors associated with septicemia in patients with chronic kidney disease; however, no preventive treatments have been identified.

Recent research has shown the use of statins has been associated with a decreased rate of sepsis and improved sepsis outcomes. The authors of this study investigated whether statin use may help reduce the incidence of sepsis in patients with chronic kidney disease on dialysis.

This prospective cohort study enrolled 1,041 participants attending dialysis clinics from October 1995 to June 1998, with a follow-up through Jan. 1, 2005. Statin use at baseline was determined by review of medical records. The primary outcome was hospitalization for sepsis, indicated by hospital data from the U.S. Renal Data System (mean follow-up 3.4 years).

The association of statin use and sepsis was assessed using two analyses. A multivariate regression analysis was performed on the entire cohort, and adjustments were made for potential confounders. An analysis was performed on a sub-cohort comparing sepsis rates in statin users with a control group identified through the likelihood of having been prescribed a statin (propensity matching).

There were 303 hospitalizations for sepsis among the 1,041 patients enrolled, with 14% of participants receiving a statin at baseline. The crude incidence rate of sepsis was 41/1,000 patient-years among statin users compared with 110/1,000 patient-years in the control group (p<0.001). The fully adjusted incidence ratio for sepsis among statin users versus nonusers was 0.38, or 62% lower among statin users.

In the propensity-matched subcohort group, there were 54 hospitalizations during follow-up. The relative risk of sepsis was 0.24 (95% confidence interval, 0.11-0.49) for statin users compared with nonusers.

A strong and independent association exists between statin use and reduced incidence of sepsis in chronic kidney disease patients. This association remained statistically significant after controlling for potential confounding. Why the statins might have this effect is not definitively known.

This national study further demonstrates the potential protective effect of statins on the occurrence of sepsis, which has been observed in previous research in a non-renal population. The author mentions that this is the first study to show a strong and significant effect of a medication administered long term on lower rates of sepsis among patients with chronic kidney disease.

Because this is an observational study, it is limited due to lack of randomization. As such, this study cannot prove causality. Further limitations include the assessment of patient and treatment factors at baseline, which can lead to a misclassification of factors that change over time. It is important to point out the study was dependent on U.S. Renal Data System and Medicare data to determine outcome, and the use of their ICD-9 coding information may have resulted in decreased reporting of sepsis.

Still, the relevant results of this investigation warrant further examination of statins and the prevention of sepsis in a prospective randomized trial. TH

Reference

1. Sarnak MJ, Jaber BL. Mortality caused by sepsis in patients with end-stage renal disease compared with the general population. Kidney Int. 2000 Oct;58(4):1758-1764.

Performance Measures and Outcomes for Heart Patients

Fonarow GC, Abraham WT, Albert NM, et al. Association between performance measures and clinical outcomes for patients hospitalized with heart failure. JAMA. 2007 Jan 3;297(1):61-70

As our population ages, more emphasis will be placed on issues surrounding efficient and evidence-based care. Heart failure, which accounted for 3.6 million hospitalizations in 2003 and has an overall prevalence of 5 million, will be at the forefront of public policy. As pay for performance (P4P) and standards of care become increasingly prevalent, the medical community will need to scrutinize the standards by which we are measured.

The American College of Cardiology and the American Heart Association (ACC/AHA) developed guidelines for the treatment and care of patients with heart failure. These measures include heart failure discharge instructions, evaluation of left ventricle (LV) function, angiotensin converting enzyme (ACE) inhibitors or angiotensin II receptor antagonist (ARB) for LV dysfunction, adult smoking cessation counseling, and anticoagulation at discharge for patients with atrial fibrillation. Adherence to these performance measures should be based on evidence.

The authors’ goal was to determine the validity of these guidelines. The Organized Program to Initiate Lifesaving Treatment in Hospitalized Patients with Heart Failure (OPTIMIZE-HF) registry allowed for the documentation and follow-up of patients adhering to the heart failure guidelines as set forth by the ACC/AHA. The study assessed the relationship between these guidelines and clinical outcomes, including 60- to 90-day mortality and a composite end point of mortality or rehospitalization.

In this study the OPTIMIZE-HF registry was used as the source of prospective data collection. Ten percent of eligible patients were randomly selected from the registry between March 2003 and December 2004 from 91 hospitals. Eligibility for the OPTIMIZE-HF registry included patients 18 and older admitted for worsening heart failure or significant heart failure during their hospital stay. The performance measure of discharge instruction, smoking cessation, and anticoagulation were measured for all eligible patients. Patients with an ejection fraction of 40% or less, or moderate to severe systolic function, were included for the ACE inhibitor/ARB performance measure. One measure not included was treatment with beta-blockers at discharge. The authors included beta-blockers at discharge with metrics similar to those described for ACE/ARB criteria.

The conformity rates and process-outcome links were then determined for the performance measures and beta-blocker treatment as it related to 60- to 90-day mortality/rehospitalization.

The study focused on a random follow-up cohort of 5,791 patients from 91 hospitals. This was similar to the OPTIMIZE-HF cohort of 48,612 patients in 259 hospitals. Demographically, the average cohort’s age was 72, 51% male and 78% white, with 42% of patients diagnosed with ischemic heart disease and 43% with diabetes mellitus. These results were similar to the demographics of the overall OPTIMIZE-HF registry.

Of the eligible patients in the follow-up cohort, 66% (4,010) received complete discharge instructions. Eighty-nine percent of eligible patients (4,664) had their left ventricular function evaluated. For those patients with documented left ventricular systolic dysfunction (2,181), 83% were given an ACE inhibitor or ARB at discharge. Patients who had a diagnosis of atrial fibrillation were discharged with anticoagulation at a rate of 53%, and 72% of patients were counseled on smoking cessation. As compared with ACE inhibitors/ARB, similar results (84%) were seen for beta-blockers at discharge.

Only two of the five ACC/AHA performance measures were predictive of decreasing morbidity and mortality/rehospitalization in unadjusted analysis: patients discharged on ACE inhibitors/ARBs (odds ratio, 0.51; 95% CI 0.34–0.78; P- .002) and smoking cessation counseling. Beta-blockers, not a formal part of the ACC/AHA guidelines, were also a predictor of lower risk of both mortality and rehospitalization (odds ratio, 0.73; 95% CI, 0.55-0.96; P-0.02)

The OPTIMIZE-HF cohort analysis allowed for an opportunity to determine the degree of conformity for the ACC/AHA performance measures. The ACE inhibitors or ARB use at discharge was shown in the OPTIMIZE-HF cohort to have a relative reduction in one-year post discharge mortality by 17% (risk reduction, 0.83; 95% CI, 0.79-0.88) and a trend to lower 60- to 90-days post-discharge mortality and rehospitalization. Although smoking cessation had an early positive correlation, outcomes did not reach statistical significance. The measure of discharge instruction in the current study did not show a benefit on early mortality/rehospitalization in 60- to 90-days post discharge. It is unclear from this study if discharge instructions given to patients were either rushed or discussed in a comprehensive manner. This factor will need clarification and further research.

The measures of discharge instructions, smoking cessation, LV assessment, and anticoagulation for atrial fibrillation have not been examined as effective performance measures prior to this study. These measures were unable to show an independent decrease in 60- to 90-day mortality and rehospitalization.

Patients discharged with beta-blockers showed an association between lower mortality and rehospitalization. This association was found to be stronger than any of the formal ACC/AHA current performance measures.

The ACC/AHA guidelines are becoming standards of care for reporting to agencies such as Centers for Medicare and Medicaid Services or other P4P programs. To allow for improvement of quality, JCAHO and ACC/AHA designed the above criteria to act as a guide for the post discharge care of coronary heart failure patients. Because these criteria are the measures by which hospitals need to report, it will be necessary for data to show validity and a link between the clinical performance measures and improved outcomes.

Of the five measures stated, only ACE inhibitors/ARB at discharge was associated with a decrease in mortality/rehospitalization. Beta-blockers, currently not a performance measure, also showed this trend. Increased scrutiny needs to be part of the criteria for which hospitals and practitioners are being held accountable, and further research validating their effectiveness is warranted.

Risk Indexes for COPD

Niewoehner DE, Lockhnygina Y, Rice K, et al. Risk indexes for exacerbations and hospitalizations due to COPD. Chest. 2007 Jan;131(1):20-28.

Chronic obstructive pulmonary disease (COPD) is a leading cause of morbidity and mortality in the U.S. and continues to increase its numbers annually.

The cornerstone of COPD diagnosis and key predictor of prognosis is a low level of lung function. Another important predictor of morbidity, mortality, and progression of disease is COPD exacerbations.

Unfortunately, the definition of an exacerbation is varied, ranging from an increase in symptoms to COPD-related hospitalizations and death.1 Therefore, prevention of COPD exacerbations is an important management goal. This study focuses on setting a risk model as a clinical management tool, similar to what exists for cardiovascular events or community acquired pneumonia. No previous study has attempted to identify risk factors for exacerbations using prospective data collection and a clearly stated definition of exacerbation.

The study was a parallel-group, randomized, double-blind, placebo-controlled trial in patients with moderate to severe COPD conducted at 26 Veterans Affairs medical centers in the United States. Subjects were 40 or older, with a cigarette smoking history of 10 packs a year or more, a clinical diagnosis of COPD, and a forced expiratory volume [FEV] of 60% or less predicted and 70% or less of the forced vital capacity [FVC].1 Patients were allocated to receive one capsule of tiotropium (18 mg) or placebo for six months.

Of the 1,829 patients selected, 914 were assigned to the tiotropium arm. Patients kept a daily diary, and the investigators collected data by monthly telephone interviews and by site visits at three and six months with spirometry evaluation. They evaluated the association between baseline characteristics, concomitant medications and the study drug and the time to first COPD exacerbation and the time to first hospitalization due to exacerbation. The authors defined an exacerbation as a complex of respiratory symptoms of more than one of the following: cough, sputum, wheezing, dyspnea, or chest tightness with a duration of at least three days requiring treatment with antibiotics and/or systemic corticosteroids and/or hospital admission.

The investigators found that a statistically significant greater risk for both COPD exacerbations and hospitalizations is associated with being of older age, being a noncurrent smoker, having poorer lung function, using home oxygen, visiting the clinic or emergency department more often, either scheduled or unscheduled, being hospitalized for COPD in the prior year, using either antibiotics or systemic steroids for COPD more often in the prior year, and using short-acting beta agonist, inhaled or oral corticosteroid at a baseline rate.

On the other hand, a statistically significant greater risk of only COPD exacerbation was seen in white patients, with presence of productive cough, longer duration of COPD, use of long-acting beta agonist or theophylline at baseline, and presence of any gastrointestinal or hepatobiliary disease. Lower body-mass index and the presence of cardiovascular comorbidity were associated with statistically significant greater risk for only hospitalization due to COPD.

The investigators also confirmed the previous suggestion that chronic cough is an independent predictor of exacerbation. Interestingly, they found that any cardiovascular comorbidity is a strong and independent predictor of hospitalizations due to COPD. It is unclear if cardiovascular disease truly predisposes subjects to COPD hospitalizations or merely represents a misdiagnosis because both diseases have similar symptoms.

Current smokers were identified as having lower risk of exacerbation and hospitalization, probably due to the “healthy smoker” theory—that deteriorating lung function causes the patient to quit smoking.

This study is the first to gather information about predictors of COPD exacerbations in a prospective fashion using a clear definition of exacerbation. The authors developed a model to assess the risk of COPD exacerbations and hospitalizations due to exacerbations in patients with moderate to severe COPD. Moreover, this model can easily be applied to individual patients and reproduced with simple spirometry and a series of questions.

Though this trial had a reasonable level of statistical significance, it is important to mention that the trial was conducted within a single health system (Veterans Affairs medical centers), there were few women in the study, and the eligibility criteria were very specific.

References

1. Mannino DM, Watt G, Hole D, et al. The natural history of chronic obstructive pulmonary disease. Eur Respir J. 2006 Mar;27(3):627-643.

Glucose Management in Hospitalized Patients

Leahy JL. Insulin Management of diabetic patients on general medical and surgical floors. Endocr Pract. Jul/Aug 2006;12(Suppl3):86-89.

Although the rationale behind the science for tight control of blood sugar in subsets of hospitalized patient populations is without debate when it comes to the majority of general ward patients, the management of hyperglycemia becomes more of an art. Increasingly we recognize the effect of the relationship between improving glucose management and improving clinical outcomes.

Guidelines for inpatient targeted blood glucose levels exist, but hospitals are moving toward a more individualized approach to subcutaneous insulin protocols for their patients, thus moving beyond the passive sliding scale era.

Institution of an insulin protocol at one such hospital, the University of Vermont, highlights such an approach. The ongoing internal nonrandomized study exemplifies a two-tiered approach initially aimed at expanding the house physician comfort zone to change the culture of hyperglycemic management beyond simply avoiding hypoglycemia to one of an active and—per our current standards—aggressive individualized insulin protocol.

It seems the author envisions a gradual process allowing initial flexibility within the protocol, increasing the intensity of dosing as comfort zones expand. Throughout the process, the principles of determining a patient’s weight-based daily insulin needs are maintained, taking into consideration factors like comorbidities, severity of illness, amount of oral intake, steroid usage, and age. Then, the insulin regimen is physiologically (basal/bolus, basal, continuous) administered according to the route (i.e., total parenteral nutrition) and timing of their nutritional intake.

Adjustments being made to insulin regimens are based on fasting, pre-meal and bedtime glucose as well as the novel approach of bolus insulin after meals with short-acting insulin (i.e., lispro).

Unfortunately although the protocol does perhaps yield itself to being looked at more stringently—in terms of cost effectiveness, improved length of hospital stay, and improved clinical outcomes—the outcome studied here was primarily one of hospitalwide education in advancing the understanding and culture of aggressive individualized insulin protocols. These can often be even more statistically difficult to quantify. As self-reported, improve­­ments were made.

One of the most important aspects of this paper is that it draws attention to the paucity of evidence for improved clinical and monetary outcomes supporting the aggressive hospital management of hyperglycemia in the non-acutely ill patient. Often, the guiding principle is to avoid hypoglycemia. Detailing the specific protocols of one such approach serves as an example for the motivated reader.

Early Switch from IV to Oral Antibiotic in Severe CAP

Oosterheert JJ, Bonten JM, Schneider MME, et al. Effectiveness of early switch from intravenous to oral antibiotics in severe community acquired pneumonia; multicentre randomised trial. BMJ. 2006 Dec 9; 333:1193.

Community acquired pneumonia (CAP) is a common and potentially fatal infection with high healthcare costs. When patients are first admitted to hospitals, antibiotics are usually given intravenously to provide optimal concentrations in the tissues.

The duration of intravenous treatment is an important determinant of length of hospital stay (LOS). The concept of early transition from intravenous to oral antibiotic in the treatment of CAP has been evaluated before, but only in mild to moderately severe disease—and rarely in randomized trials.

This multicenter random controlled trial from five teaching hospitals and two medical centers in the Netherlands enrolled 302 patients in non-intensive care units with severe CAP. The primary outcome was clinical cure and secondary outcome was LOS. The inclusion criteria were adults 18 or older with severe CAP; mean pneumonia severity index of IV-V, new progressive infiltrate on chest X-ray, plus at least two other criteria (cough, sputum production, rectal temperature >38o C or <36.1o C, auscultative findings consistent with pneumonia, leukocytes >109 WBC/L or >15% bands, positive cultures of blob or pleural fluids, CRP three times greater times upper limit of normal).

Exclusion criteria included the need for mechanical ventilation, cystic fibrosis, a history of colonization with gram-negative bacteria due to structural damage to the respiratory tract, malfunction of the digestive tract, life expectancy of less than one month because of underlying disease, infections other than pneumonia that needed antibiotic treatment, and severe immunosuppression (neutropenia [<0.5 109 neutrophils/liter] or a CD4 count< 200/mm3).

Treatment failure was defined as death, still in hospital at day 28 of the study, or clinical deterioration (increase in temperature after initial improvement or the need for mechanical ventilation, switch back to intravenous antibiotics, or readmission for pulmonary reinfection after discharge).

Clinical cure was defined as discharged in good health without signs and symptoms of pneumonia and no treatment failure during follow-up.

The control group comprised 150 subjects who were to receive a standard course of seven days’ intravenous treatment. Meanwhile, 152 subjects were randomized to the early switch group. Baseline characteristics were similar in both groups. More than 80% of patients were in pneumonia severity class IV or V. Most patients received empirical monotherapy with amoxicillin or amoxicillin plus clavulanic acid (n=174; 58%) or a cephalosporin (n=59; 20%), which is in line with Dutch prescribing policies.

The most frequently identified microorganism was S pneumoniae (n=76; 25%). Atypical pathogens were detected in 33 patients (11%). Before day three, 37 patients (12%) were excluded from analysis, leaving 132 patients for analysis in the intervention group and 133 in the control group.

Reasons for exclusion included when the initial diagnosis of CAP was replaced by another diagnosis (n=9), consent was withdrawn (n=11), the protocol was violated (n=4), the patient was admitted to an intensive-care unit for mechanical ventilation (n=6), and the patient died (n=7). After three days of intravenous treatment, 108 of 132 patients (81%) in the intervention group were switched to oral treatment, of whom 102 (94%) received amoxicillin plus clavulanic acid (500+125 mg every eight hours).

In the control group, five patients did not receive intravenous antibiotics for all seven days because of phlebitis associated with intravenous treatment; none of them needed treatment for line-related sepsis. Overall duration of antibiotic treatment was 10.1 days in the intervention group and 9.3 days in the control group (mean difference 0.8 days, 95% confidence interval -0.6 to 2.0).

The duration of intravenous treatment was significantly shorter in the intervention group (mean 3.6 [SD 1.5] versus 7.0 [2.0] days, mean difference 3.4, 2.8 to 3.9). Average time to meet the discharge criteria was 5.2 (2.9) days in the intervention group and 5.7 (3.1) days in the control group (0.5 days -0.3 to 1.2) Total length of hospital stay was 9.6 (5.0) and 11.5 (4.9) days for patients in the intervention group and control group (1.9 days 0.6 to 3.2).

The authors’ findings provide strong evidence that early transition from intravenous to oral antibiotic is also viable in patients with highly graded Pneumonia Severity Index (PSI) CAP, not only in mild to moderately severe disease. This leads to reduced LOS, cost, and possibly reduced risk of line infections and increased patient satisfaction for early discharge.

Note: This study was done with patients suffering straightforward, uncomplicated CAP. The investigators’ findings cannot be applied to patients with other comorbidities like diabetes, COPD, heart failure, or sickle cell, which might require more days on intravenous antibiotic. One might also wonder what impact would have been seen had 37 patients not dropped off, and if another class of oral antibiotic such as quinolones had been used.

Last, the study sample showed S pneumoniae identified in 25% of cases and atypical pathogens to be 11%. What then are the majority of pathogens identified 64% of the time? This would have been another key factor that might have had a great effect on the result.

Although a larger sampling and further risk stratification (to include patients with other comorbidities) are needed, this study makes a valid point for early transition to oral antibiotics in highly graded, uncomplicated CAP. TH

Performance Measures and Outcomes for Heart Patients

Fonarow GC, Abraham WT, Albert NM, et al. Association between performance measures and clinical outcomes for patients hospitalized with heart failure. JAMA. 2007 Jan 3;297(1):61-70

As our population ages, more emphasis will be placed on issues surrounding efficient and evidence-based care. Heart failure, which accounted for 3.6 million hospitalizations in 2003 and has an overall prevalence of 5 million, will be at the forefront of public policy. As pay for performance (P4P) and standards of care become increasingly prevalent, the medical community will need to scrutinize the standards by which we are measured.

The American College of Cardiology and the American Heart Association (ACC/AHA) developed guidelines for the treatment and care of patients with heart failure. These measures include heart failure discharge instructions, evaluation of left ventricle (LV) function, angiotensin converting enzyme (ACE) inhibitors or angiotensin II receptor antagonist (ARB) for LV dysfunction, adult smoking cessation counseling, and anticoagulation at discharge for patients with atrial fibrillation. Adherence to these performance measures should be based on evidence.

The authors’ goal was to determine the validity of these guidelines. The Organized Program to Initiate Lifesaving Treatment in Hospitalized Patients with Heart Failure (OPTIMIZE-HF) registry allowed for the documentation and follow-up of patients adhering to the heart failure guidelines as set forth by the ACC/AHA. The study assessed the relationship between these guidelines and clinical outcomes, including 60- to 90-day mortality and a composite end point of mortality or rehospitalization.

In this study the OPTIMIZE-HF registry was used as the source of prospective data collection. Ten percent of eligible patients were randomly selected from the registry between March 2003 and December 2004 from 91 hospitals. Eligibility for the OPTIMIZE-HF registry included patients 18 and older admitted for worsening heart failure or significant heart failure during their hospital stay. The performance measure of discharge instruction, smoking cessation, and anticoagulation were measured for all eligible patients. Patients with an ejection fraction of 40% or less, or moderate to severe systolic function, were included for the ACE inhibitor/ARB performance measure. One measure not included was treatment with beta-blockers at discharge. The authors included beta-blockers at discharge with metrics similar to those described for ACE/ARB criteria.

The conformity rates and process-outcome links were then determined for the performance measures and beta-blocker treatment as it related to 60- to 90-day mortality/rehospitalization.

The study focused on a random follow-up cohort of 5,791 patients from 91 hospitals. This was similar to the OPTIMIZE-HF cohort of 48,612 patients in 259 hospitals. Demographically, the average cohort’s age was 72, 51% male and 78% white, with 42% of patients diagnosed with ischemic heart disease and 43% with diabetes mellitus. These results were similar to the demographics of the overall OPTIMIZE-HF registry.

Of the eligible patients in the follow-up cohort, 66% (4,010) received complete discharge instructions. Eighty-nine percent of eligible patients (4,664) had their left ventricular function evaluated. For those patients with documented left ventricular systolic dysfunction (2,181), 83% were given an ACE inhibitor or ARB at discharge. Patients who had a diagnosis of atrial fibrillation were discharged with anticoagulation at a rate of 53%, and 72% of patients were counseled on smoking cessation. As compared with ACE inhibitors/ARB, similar results (84%) were seen for beta-blockers at discharge.

Only two of the five ACC/AHA performance measures were predictive of decreasing morbidity and mortality/rehospitalization in unadjusted analysis: patients discharged on ACE inhibitors/ARBs (odds ratio, 0.51; 95% CI 0.34–0.78; P- .002) and smoking cessation counseling. Beta-blockers, not a formal part of the ACC/AHA guidelines, were also a predictor of lower risk of both mortality and rehospitalization (odds ratio, 0.73; 95% CI, 0.55-0.96; P-0.02)

The OPTIMIZE-HF cohort analysis allowed for an opportunity to determine the degree of conformity for the ACC/AHA performance measures. The ACE inhibitors or ARB use at discharge was shown in the OPTIMIZE-HF cohort to have a relative reduction in one-year post discharge mortality by 17% (risk reduction, 0.83; 95% CI, 0.79-0.88) and a trend to lower 60- to 90-days post-discharge mortality and rehospitalization. Although smoking cessation had an early positive correlation, outcomes did not reach statistical significance. The measure of discharge instruction in the current study did not show a benefit on early mortality/rehospitalization in 60- to 90-days post discharge. It is unclear from this study if discharge instructions given to patients were either rushed or discussed in a comprehensive manner. This factor will need clarification and further research.

The measures of discharge instructions, smoking cessation, LV assessment, and anticoagulation for atrial fibrillation have not been examined as effective performance measures prior to this study. These measures were unable to show an independent decrease in 60- to 90-day mortality and rehospitalization.

Patients discharged with beta-blockers showed an association between lower mortality and rehospitalization. This association was found to be stronger than any of the formal ACC/AHA current performance measures.

The ACC/AHA guidelines are becoming standards of care for reporting to agencies such as Centers for Medicare and Medicaid Services or other P4P programs. To allow for improvement of quality, JCAHO and ACC/AHA designed the above criteria to act as a guide for the post discharge care of coronary heart failure patients. Because these criteria are the measures by which hospitals need to report, it will be necessary for data to show validity and a link between the clinical performance measures and improved outcomes.

Of the five measures stated, only ACE inhibitors/ARB at discharge was associated with a decrease in mortality/rehospitalization. Beta-blockers, currently not a performance measure, also showed this trend. Increased scrutiny needs to be part of the criteria for which hospitals and practitioners are being held accountable, and further research validating their effectiveness is warranted.

Risk Indexes for COPD

Niewoehner DE, Lockhnygina Y, Rice K, et al. Risk indexes for exacerbations and hospitalizations due to COPD. Chest. 2007 Jan;131(1):20-28.

Chronic obstructive pulmonary disease (COPD) is a leading cause of morbidity and mortality in the U.S. and continues to increase its numbers annually.

The cornerstone of COPD diagnosis and key predictor of prognosis is a low level of lung function. Another important predictor of morbidity, mortality, and progression of disease is COPD exacerbations.

Unfortunately, the definition of an exacerbation is varied, ranging from an increase in symptoms to COPD-related hospitalizations and death.1 Therefore, prevention of COPD exacerbations is an important management goal. This study focuses on setting a risk model as a clinical management tool, similar to what exists for cardiovascular events or community acquired pneumonia. No previous study has attempted to identify risk factors for exacerbations using prospective data collection and a clearly stated definition of exacerbation.

The study was a parallel-group, randomized, double-blind, placebo-controlled trial in patients with moderate to severe COPD conducted at 26 Veterans Affairs medical centers in the United States. Subjects were 40 or older, with a cigarette smoking history of 10 packs a year or more, a clinical diagnosis of COPD, and a forced expiratory volume [FEV] of 60% or less predicted and 70% or less of the forced vital capacity [FVC].1 Patients were allocated to receive one capsule of tiotropium (18 mg) or placebo for six months.

Of the 1,829 patients selected, 914 were assigned to the tiotropium arm. Patients kept a daily diary, and the investigators collected data by monthly telephone interviews and by site visits at three and six months with spirometry evaluation. They evaluated the association between baseline characteristics, concomitant medications and the study drug and the time to first COPD exacerbation and the time to first hospitalization due to exacerbation. The authors defined an exacerbation as a complex of respiratory symptoms of more than one of the following: cough, sputum, wheezing, dyspnea, or chest tightness with a duration of at least three days requiring treatment with antibiotics and/or systemic corticosteroids and/or hospital admission.

The investigators found that a statistically significant greater risk for both COPD exacerbations and hospitalizations is associated with being of older age, being a noncurrent smoker, having poorer lung function, using home oxygen, visiting the clinic or emergency department more often, either scheduled or unscheduled, being hospitalized for COPD in the prior year, using either antibiotics or systemic steroids for COPD more often in the prior year, and using short-acting beta agonist, inhaled or oral corticosteroid at a baseline rate.

On the other hand, a statistically significant greater risk of only COPD exacerbation was seen in white patients, with presence of productive cough, longer duration of COPD, use of long-acting beta agonist or theophylline at baseline, and presence of any gastrointestinal or hepatobiliary disease. Lower body-mass index and the presence of cardiovascular comorbidity were associated with statistically significant greater risk for only hospitalization due to COPD.

The investigators also confirmed the previous suggestion that chronic cough is an independent predictor of exacerbation. Interestingly, they found that any cardiovascular comorbidity is a strong and independent predictor of hospitalizations due to COPD. It is unclear if cardiovascular disease truly predisposes subjects to COPD hospitalizations or merely represents a misdiagnosis because both diseases have similar symptoms.

Current smokers were identified as having lower risk of exacerbation and hospitalization, probably due to the “healthy smoker” theory—that deteriorating lung function causes the patient to quit smoking.

This study is the first to gather information about predictors of COPD exacerbations in a prospective fashion using a clear definition of exacerbation. The authors developed a model to assess the risk of COPD exacerbations and hospitalizations due to exacerbations in patients with moderate to severe COPD. Moreover, this model can easily be applied to individual patients and reproduced with simple spirometry and a series of questions.

Though this trial had a reasonable level of statistical significance, it is important to mention that the trial was conducted within a single health system (Veterans Affairs medical centers), there were few women in the study, and the eligibility criteria were very specific.

References

1. Mannino DM, Watt G, Hole D, et al. The natural history of chronic obstructive pulmonary disease. Eur Respir J. 2006 Mar;27(3):627-643.

Glucose Management in Hospitalized Patients

Leahy JL. Insulin Management of diabetic patients on general medical and surgical floors. Endocr Pract. Jul/Aug 2006;12(Suppl3):86-89.

Although the rationale behind the science for tight control of blood sugar in subsets of hospitalized patient populations is without debate when it comes to the majority of general ward patients, the management of hyperglycemia becomes more of an art. Increasingly we recognize the effect of the relationship between improving glucose management and improving clinical outcomes.

Guidelines for inpatient targeted blood glucose levels exist, but hospitals are moving toward a more individualized approach to subcutaneous insulin protocols for their patients, thus moving beyond the passive sliding scale era.

Institution of an insulin protocol at one such hospital, the University of Vermont, highlights such an approach. The ongoing internal nonrandomized study exemplifies a two-tiered approach initially aimed at expanding the house physician comfort zone to change the culture of hyperglycemic management beyond simply avoiding hypoglycemia to one of an active and—per our current standards—aggressive individualized insulin protocol.

It seems the author envisions a gradual process allowing initial flexibility within the protocol, increasing the intensity of dosing as comfort zones expand. Throughout the process, the principles of determining a patient’s weight-based daily insulin needs are maintained, taking into consideration factors like comorbidities, severity of illness, amount of oral intake, steroid usage, and age. Then, the insulin regimen is physiologically (basal/bolus, basal, continuous) administered according to the route (i.e., total parenteral nutrition) and timing of their nutritional intake.

Adjustments being made to insulin regimens are based on fasting, pre-meal and bedtime glucose as well as the novel approach of bolus insulin after meals with short-acting insulin (i.e., lispro).

Unfortunately although the protocol does perhaps yield itself to being looked at more stringently—in terms of cost effectiveness, improved length of hospital stay, and improved clinical outcomes—the outcome studied here was primarily one of hospitalwide education in advancing the understanding and culture of aggressive individualized insulin protocols. These can often be even more statistically difficult to quantify. As self-reported, improve­­ments were made.

One of the most important aspects of this paper is that it draws attention to the paucity of evidence for improved clinical and monetary outcomes supporting the aggressive hospital management of hyperglycemia in the non-acutely ill patient. Often, the guiding principle is to avoid hypoglycemia. Detailing the specific protocols of one such approach serves as an example for the motivated reader.

Early Switch from IV to Oral Antibiotic in Severe CAP

Oosterheert JJ, Bonten JM, Schneider MME, et al. Effectiveness of early switch from intravenous to oral antibiotics in severe community acquired pneumonia; multicentre randomised trial. BMJ. 2006 Dec 9; 333:1193.

Community acquired pneumonia (CAP) is a common and potentially fatal infection with high healthcare costs. When patients are first admitted to hospitals, antibiotics are usually given intravenously to provide optimal concentrations in the tissues.

The duration of intravenous treatment is an important determinant of length of hospital stay (LOS). The concept of early transition from intravenous to oral antibiotic in the treatment of CAP has been evaluated before, but only in mild to moderately severe disease—and rarely in randomized trials.

This multicenter random controlled trial from five teaching hospitals and two medical centers in the Netherlands enrolled 302 patients in non-intensive care units with severe CAP. The primary outcome was clinical cure and secondary outcome was LOS. The inclusion criteria were adults 18 or older with severe CAP; mean pneumonia severity index of IV-V, new progressive infiltrate on chest X-ray, plus at least two other criteria (cough, sputum production, rectal temperature >38o C or <36.1o C, auscultative findings consistent with pneumonia, leukocytes >109 WBC/L or >15% bands, positive cultures of blob or pleural fluids, CRP three times greater times upper limit of normal).

Exclusion criteria included the need for mechanical ventilation, cystic fibrosis, a history of colonization with gram-negative bacteria due to structural damage to the respiratory tract, malfunction of the digestive tract, life expectancy of less than one month because of underlying disease, infections other than pneumonia that needed antibiotic treatment, and severe immunosuppression (neutropenia [<0.5 109 neutrophils/liter] or a CD4 count< 200/mm3).

Treatment failure was defined as death, still in hospital at day 28 of the study, or clinical deterioration (increase in temperature after initial improvement or the need for mechanical ventilation, switch back to intravenous antibiotics, or readmission for pulmonary reinfection after discharge).

Clinical cure was defined as discharged in good health without signs and symptoms of pneumonia and no treatment failure during follow-up.

The control group comprised 150 subjects who were to receive a standard course of seven days’ intravenous treatment. Meanwhile, 152 subjects were randomized to the early switch group. Baseline characteristics were similar in both groups. More than 80% of patients were in pneumonia severity class IV or V. Most patients received empirical monotherapy with amoxicillin or amoxicillin plus clavulanic acid (n=174; 58%) or a cephalosporin (n=59; 20%), which is in line with Dutch prescribing policies.

The most frequently identified microorganism was S pneumoniae (n=76; 25%). Atypical pathogens were detected in 33 patients (11%). Before day three, 37 patients (12%) were excluded from analysis, leaving 132 patients for analysis in the intervention group and 133 in the control group.

Reasons for exclusion included when the initial diagnosis of CAP was replaced by another diagnosis (n=9), consent was withdrawn (n=11), the protocol was violated (n=4), the patient was admitted to an intensive-care unit for mechanical ventilation (n=6), and the patient died (n=7). After three days of intravenous treatment, 108 of 132 patients (81%) in the intervention group were switched to oral treatment, of whom 102 (94%) received amoxicillin plus clavulanic acid (500+125 mg every eight hours).

In the control group, five patients did not receive intravenous antibiotics for all seven days because of phlebitis associated with intravenous treatment; none of them needed treatment for line-related sepsis. Overall duration of antibiotic treatment was 10.1 days in the intervention group and 9.3 days in the control group (mean difference 0.8 days, 95% confidence interval -0.6 to 2.0).

The duration of intravenous treatment was significantly shorter in the intervention group (mean 3.6 [SD 1.5] versus 7.0 [2.0] days, mean difference 3.4, 2.8 to 3.9). Average time to meet the discharge criteria was 5.2 (2.9) days in the intervention group and 5.7 (3.1) days in the control group (0.5 days -0.3 to 1.2) Total length of hospital stay was 9.6 (5.0) and 11.5 (4.9) days for patients in the intervention group and control group (1.9 days 0.6 to 3.2).

The authors’ findings provide strong evidence that early transition from intravenous to oral antibiotic is also viable in patients with highly graded Pneumonia Severity Index (PSI) CAP, not only in mild to moderately severe disease. This leads to reduced LOS, cost, and possibly reduced risk of line infections and increased patient satisfaction for early discharge.

Note: This study was done with patients suffering straightforward, uncomplicated CAP. The investigators’ findings cannot be applied to patients with other comorbidities like diabetes, COPD, heart failure, or sickle cell, which might require more days on intravenous antibiotic. One might also wonder what impact would have been seen had 37 patients not dropped off, and if another class of oral antibiotic such as quinolones had been used.

Last, the study sample showed S pneumoniae identified in 25% of cases and atypical pathogens to be 11%. What then are the majority of pathogens identified 64% of the time? This would have been another key factor that might have had a great effect on the result.

Although a larger sampling and further risk stratification (to include patients with other comorbidities) are needed, this study makes a valid point for early transition to oral antibiotics in highly graded, uncomplicated CAP. TH

Performance Measures and Outcomes for Heart Patients

Fonarow GC, Abraham WT, Albert NM, et al. Association between performance measures and clinical outcomes for patients hospitalized with heart failure. JAMA. 2007 Jan 3;297(1):61-70

As our population ages, more emphasis will be placed on issues surrounding efficient and evidence-based care. Heart failure, which accounted for 3.6 million hospitalizations in 2003 and has an overall prevalence of 5 million, will be at the forefront of public policy. As pay for performance (P4P) and standards of care become increasingly prevalent, the medical community will need to scrutinize the standards by which we are measured.

The American College of Cardiology and the American Heart Association (ACC/AHA) developed guidelines for the treatment and care of patients with heart failure. These measures include heart failure discharge instructions, evaluation of left ventricle (LV) function, angiotensin converting enzyme (ACE) inhibitors or angiotensin II receptor antagonist (ARB) for LV dysfunction, adult smoking cessation counseling, and anticoagulation at discharge for patients with atrial fibrillation. Adherence to these performance measures should be based on evidence.

The authors’ goal was to determine the validity of these guidelines. The Organized Program to Initiate Lifesaving Treatment in Hospitalized Patients with Heart Failure (OPTIMIZE-HF) registry allowed for the documentation and follow-up of patients adhering to the heart failure guidelines as set forth by the ACC/AHA. The study assessed the relationship between these guidelines and clinical outcomes, including 60- to 90-day mortality and a composite end point of mortality or rehospitalization.

In this study the OPTIMIZE-HF registry was used as the source of prospective data collection. Ten percent of eligible patients were randomly selected from the registry between March 2003 and December 2004 from 91 hospitals. Eligibility for the OPTIMIZE-HF registry included patients 18 and older admitted for worsening heart failure or significant heart failure during their hospital stay. The performance measure of discharge instruction, smoking cessation, and anticoagulation were measured for all eligible patients. Patients with an ejection fraction of 40% or less, or moderate to severe systolic function, were included for the ACE inhibitor/ARB performance measure. One measure not included was treatment with beta-blockers at discharge. The authors included beta-blockers at discharge with metrics similar to those described for ACE/ARB criteria.

The conformity rates and process-outcome links were then determined for the performance measures and beta-blocker treatment as it related to 60- to 90-day mortality/rehospitalization.

The study focused on a random follow-up cohort of 5,791 patients from 91 hospitals. This was similar to the OPTIMIZE-HF cohort of 48,612 patients in 259 hospitals. Demographically, the average cohort’s age was 72, 51% male and 78% white, with 42% of patients diagnosed with ischemic heart disease and 43% with diabetes mellitus. These results were similar to the demographics of the overall OPTIMIZE-HF registry.

Of the eligible patients in the follow-up cohort, 66% (4,010) received complete discharge instructions. Eighty-nine percent of eligible patients (4,664) had their left ventricular function evaluated. For those patients with documented left ventricular systolic dysfunction (2,181), 83% were given an ACE inhibitor or ARB at discharge. Patients who had a diagnosis of atrial fibrillation were discharged with anticoagulation at a rate of 53%, and 72% of patients were counseled on smoking cessation. As compared with ACE inhibitors/ARB, similar results (84%) were seen for beta-blockers at discharge.

Only two of the five ACC/AHA performance measures were predictive of decreasing morbidity and mortality/rehospitalization in unadjusted analysis: patients discharged on ACE inhibitors/ARBs (odds ratio, 0.51; 95% CI 0.34–0.78; P- .002) and smoking cessation counseling. Beta-blockers, not a formal part of the ACC/AHA guidelines, were also a predictor of lower risk of both mortality and rehospitalization (odds ratio, 0.73; 95% CI, 0.55-0.96; P-0.02)

The OPTIMIZE-HF cohort analysis allowed for an opportunity to determine the degree of conformity for the ACC/AHA performance measures. The ACE inhibitors or ARB use at discharge was shown in the OPTIMIZE-HF cohort to have a relative reduction in one-year post discharge mortality by 17% (risk reduction, 0.83; 95% CI, 0.79-0.88) and a trend to lower 60- to 90-days post-discharge mortality and rehospitalization. Although smoking cessation had an early positive correlation, outcomes did not reach statistical significance. The measure of discharge instruction in the current study did not show a benefit on early mortality/rehospitalization in 60- to 90-days post discharge. It is unclear from this study if discharge instructions given to patients were either rushed or discussed in a comprehensive manner. This factor will need clarification and further research.

The measures of discharge instructions, smoking cessation, LV assessment, and anticoagulation for atrial fibrillation have not been examined as effective performance measures prior to this study. These measures were unable to show an independent decrease in 60- to 90-day mortality and rehospitalization.

Patients discharged with beta-blockers showed an association between lower mortality and rehospitalization. This association was found to be stronger than any of the formal ACC/AHA current performance measures.

The ACC/AHA guidelines are becoming standards of care for reporting to agencies such as Centers for Medicare and Medicaid Services or other P4P programs. To allow for improvement of quality, JCAHO and ACC/AHA designed the above criteria to act as a guide for the post discharge care of coronary heart failure patients. Because these criteria are the measures by which hospitals need to report, it will be necessary for data to show validity and a link between the clinical performance measures and improved outcomes.

Of the five measures stated, only ACE inhibitors/ARB at discharge was associated with a decrease in mortality/rehospitalization. Beta-blockers, currently not a performance measure, also showed this trend. Increased scrutiny needs to be part of the criteria for which hospitals and practitioners are being held accountable, and further research validating their effectiveness is warranted.

Risk Indexes for COPD

Niewoehner DE, Lockhnygina Y, Rice K, et al. Risk indexes for exacerbations and hospitalizations due to COPD. Chest. 2007 Jan;131(1):20-28.

Chronic obstructive pulmonary disease (COPD) is a leading cause of morbidity and mortality in the U.S. and continues to increase its numbers annually.

The cornerstone of COPD diagnosis and key predictor of prognosis is a low level of lung function. Another important predictor of morbidity, mortality, and progression of disease is COPD exacerbations.

Unfortunately, the definition of an exacerbation is varied, ranging from an increase in symptoms to COPD-related hospitalizations and death.1 Therefore, prevention of COPD exacerbations is an important management goal. This study focuses on setting a risk model as a clinical management tool, similar to what exists for cardiovascular events or community acquired pneumonia. No previous study has attempted to identify risk factors for exacerbations using prospective data collection and a clearly stated definition of exacerbation.

The study was a parallel-group, randomized, double-blind, placebo-controlled trial in patients with moderate to severe COPD conducted at 26 Veterans Affairs medical centers in the United States. Subjects were 40 or older, with a cigarette smoking history of 10 packs a year or more, a clinical diagnosis of COPD, and a forced expiratory volume [FEV] of 60% or less predicted and 70% or less of the forced vital capacity [FVC].1 Patients were allocated to receive one capsule of tiotropium (18 mg) or placebo for six months.

Of the 1,829 patients selected, 914 were assigned to the tiotropium arm. Patients kept a daily diary, and the investigators collected data by monthly telephone interviews and by site visits at three and six months with spirometry evaluation. They evaluated the association between baseline characteristics, concomitant medications and the study drug and the time to first COPD exacerbation and the time to first hospitalization due to exacerbation. The authors defined an exacerbation as a complex of respiratory symptoms of more than one of the following: cough, sputum, wheezing, dyspnea, or chest tightness with a duration of at least three days requiring treatment with antibiotics and/or systemic corticosteroids and/or hospital admission.

The investigators found that a statistically significant greater risk for both COPD exacerbations and hospitalizations is associated with being of older age, being a noncurrent smoker, having poorer lung function, using home oxygen, visiting the clinic or emergency department more often, either scheduled or unscheduled, being hospitalized for COPD in the prior year, using either antibiotics or systemic steroids for COPD more often in the prior year, and using short-acting beta agonist, inhaled or oral corticosteroid at a baseline rate.

On the other hand, a statistically significant greater risk of only COPD exacerbation was seen in white patients, with presence of productive cough, longer duration of COPD, use of long-acting beta agonist or theophylline at baseline, and presence of any gastrointestinal or hepatobiliary disease. Lower body-mass index and the presence of cardiovascular comorbidity were associated with statistically significant greater risk for only hospitalization due to COPD.

The investigators also confirmed the previous suggestion that chronic cough is an independent predictor of exacerbation. Interestingly, they found that any cardiovascular comorbidity is a strong and independent predictor of hospitalizations due to COPD. It is unclear if cardiovascular disease truly predisposes subjects to COPD hospitalizations or merely represents a misdiagnosis because both diseases have similar symptoms.

Current smokers were identified as having lower risk of exacerbation and hospitalization, probably due to the “healthy smoker” theory—that deteriorating lung function causes the patient to quit smoking.

This study is the first to gather information about predictors of COPD exacerbations in a prospective fashion using a clear definition of exacerbation. The authors developed a model to assess the risk of COPD exacerbations and hospitalizations due to exacerbations in patients with moderate to severe COPD. Moreover, this model can easily be applied to individual patients and reproduced with simple spirometry and a series of questions.

Though this trial had a reasonable level of statistical significance, it is important to mention that the trial was conducted within a single health system (Veterans Affairs medical centers), there were few women in the study, and the eligibility criteria were very specific.

References

1. Mannino DM, Watt G, Hole D, et al. The natural history of chronic obstructive pulmonary disease. Eur Respir J. 2006 Mar;27(3):627-643.

Glucose Management in Hospitalized Patients

Leahy JL. Insulin Management of diabetic patients on general medical and surgical floors. Endocr Pract. Jul/Aug 2006;12(Suppl3):86-89.

Although the rationale behind the science for tight control of blood sugar in subsets of hospitalized patient populations is without debate when it comes to the majority of general ward patients, the management of hyperglycemia becomes more of an art. Increasingly we recognize the effect of the relationship between improving glucose management and improving clinical outcomes.

Guidelines for inpatient targeted blood glucose levels exist, but hospitals are moving toward a more individualized approach to subcutaneous insulin protocols for their patients, thus moving beyond the passive sliding scale era.

Institution of an insulin protocol at one such hospital, the University of Vermont, highlights such an approach. The ongoing internal nonrandomized study exemplifies a two-tiered approach initially aimed at expanding the house physician comfort zone to change the culture of hyperglycemic management beyond simply avoiding hypoglycemia to one of an active and—per our current standards—aggressive individualized insulin protocol.

It seems the author envisions a gradual process allowing initial flexibility within the protocol, increasing the intensity of dosing as comfort zones expand. Throughout the process, the principles of determining a patient’s weight-based daily insulin needs are maintained, taking into consideration factors like comorbidities, severity of illness, amount of oral intake, steroid usage, and age. Then, the insulin regimen is physiologically (basal/bolus, basal, continuous) administered according to the route (i.e., total parenteral nutrition) and timing of their nutritional intake.

Adjustments being made to insulin regimens are based on fasting, pre-meal and bedtime glucose as well as the novel approach of bolus insulin after meals with short-acting insulin (i.e., lispro).

Unfortunately although the protocol does perhaps yield itself to being looked at more stringently—in terms of cost effectiveness, improved length of hospital stay, and improved clinical outcomes—the outcome studied here was primarily one of hospitalwide education in advancing the understanding and culture of aggressive individualized insulin protocols. These can often be even more statistically difficult to quantify. As self-reported, improve­­ments were made.

One of the most important aspects of this paper is that it draws attention to the paucity of evidence for improved clinical and monetary outcomes supporting the aggressive hospital management of hyperglycemia in the non-acutely ill patient. Often, the guiding principle is to avoid hypoglycemia. Detailing the specific protocols of one such approach serves as an example for the motivated reader.

Early Switch from IV to Oral Antibiotic in Severe CAP

Oosterheert JJ, Bonten JM, Schneider MME, et al. Effectiveness of early switch from intravenous to oral antibiotics in severe community acquired pneumonia; multicentre randomised trial. BMJ. 2006 Dec 9; 333:1193.

Community acquired pneumonia (CAP) is a common and potentially fatal infection with high healthcare costs. When patients are first admitted to hospitals, antibiotics are usually given intravenously to provide optimal concentrations in the tissues.

The duration of intravenous treatment is an important determinant of length of hospital stay (LOS). The concept of early transition from intravenous to oral antibiotic in the treatment of CAP has been evaluated before, but only in mild to moderately severe disease—and rarely in randomized trials.

This multicenter random controlled trial from five teaching hospitals and two medical centers in the Netherlands enrolled 302 patients in non-intensive care units with severe CAP. The primary outcome was clinical cure and secondary outcome was LOS. The inclusion criteria were adults 18 or older with severe CAP; mean pneumonia severity index of IV-V, new progressive infiltrate on chest X-ray, plus at least two other criteria (cough, sputum production, rectal temperature >38o C or <36.1o C, auscultative findings consistent with pneumonia, leukocytes >109 WBC/L or >15% bands, positive cultures of blob or pleural fluids, CRP three times greater times upper limit of normal).

Exclusion criteria included the need for mechanical ventilation, cystic fibrosis, a history of colonization with gram-negative bacteria due to structural damage to the respiratory tract, malfunction of the digestive tract, life expectancy of less than one month because of underlying disease, infections other than pneumonia that needed antibiotic treatment, and severe immunosuppression (neutropenia [<0.5 109 neutrophils/liter] or a CD4 count< 200/mm3).

Treatment failure was defined as death, still in hospital at day 28 of the study, or clinical deterioration (increase in temperature after initial improvement or the need for mechanical ventilation, switch back to intravenous antibiotics, or readmission for pulmonary reinfection after discharge).

Clinical cure was defined as discharged in good health without signs and symptoms of pneumonia and no treatment failure during follow-up.

The control group comprised 150 subjects who were to receive a standard course of seven days’ intravenous treatment. Meanwhile, 152 subjects were randomized to the early switch group. Baseline characteristics were similar in both groups. More than 80% of patients were in pneumonia severity class IV or V. Most patients received empirical monotherapy with amoxicillin or amoxicillin plus clavulanic acid (n=174; 58%) or a cephalosporin (n=59; 20%), which is in line with Dutch prescribing policies.

The most frequently identified microorganism was S pneumoniae (n=76; 25%). Atypical pathogens were detected in 33 patients (11%). Before day three, 37 patients (12%) were excluded from analysis, leaving 132 patients for analysis in the intervention group and 133 in the control group.

Reasons for exclusion included when the initial diagnosis of CAP was replaced by another diagnosis (n=9), consent was withdrawn (n=11), the protocol was violated (n=4), the patient was admitted to an intensive-care unit for mechanical ventilation (n=6), and the patient died (n=7). After three days of intravenous treatment, 108 of 132 patients (81%) in the intervention group were switched to oral treatment, of whom 102 (94%) received amoxicillin plus clavulanic acid (500+125 mg every eight hours).

In the control group, five patients did not receive intravenous antibiotics for all seven days because of phlebitis associated with intravenous treatment; none of them needed treatment for line-related sepsis. Overall duration of antibiotic treatment was 10.1 days in the intervention group and 9.3 days in the control group (mean difference 0.8 days, 95% confidence interval -0.6 to 2.0).

The duration of intravenous treatment was significantly shorter in the intervention group (mean 3.6 [SD 1.5] versus 7.0 [2.0] days, mean difference 3.4, 2.8 to 3.9). Average time to meet the discharge criteria was 5.2 (2.9) days in the intervention group and 5.7 (3.1) days in the control group (0.5 days -0.3 to 1.2) Total length of hospital stay was 9.6 (5.0) and 11.5 (4.9) days for patients in the intervention group and control group (1.9 days 0.6 to 3.2).

The authors’ findings provide strong evidence that early transition from intravenous to oral antibiotic is also viable in patients with highly graded Pneumonia Severity Index (PSI) CAP, not only in mild to moderately severe disease. This leads to reduced LOS, cost, and possibly reduced risk of line infections and increased patient satisfaction for early discharge.

Note: This study was done with patients suffering straightforward, uncomplicated CAP. The investigators’ findings cannot be applied to patients with other comorbidities like diabetes, COPD, heart failure, or sickle cell, which might require more days on intravenous antibiotic. One might also wonder what impact would have been seen had 37 patients not dropped off, and if another class of oral antibiotic such as quinolones had been used.

Last, the study sample showed S pneumoniae identified in 25% of cases and atypical pathogens to be 11%. What then are the majority of pathogens identified 64% of the time? This would have been another key factor that might have had a great effect on the result.

Although a larger sampling and further risk stratification (to include patients with other comorbidities) are needed, this study makes a valid point for early transition to oral antibiotics in highly graded, uncomplicated CAP. TH